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Piedrabuena MA, Correale J, Fiol M, Marrodan M, Rojas JI, Alonso M, Pappolla A, Miguez J, Patrucco L, Cristiano E, Vrech C, Cohen L, Alonso R, Silva B, Luetic G, Deri N, Burgos M, Liwacki S, Piedrabuena R, Tkachuk V, Barboza A, Martinez A, Balbuena ME, Pinheiro AA, Nofal P, Lopez PA, Tavolini D, Leguizamon F, Hryb JP, Tizio S, Recchia L, Reich E, Contentti EC, Marcilla MP, Pagani F, Cabrera LM, Curbelo MC, Mainella C, Liguori NF, Coppola M, Pettinicchi JP, Carra A, Jose G, Nadur D, Bestoso S, Pestchanker C, Vazquez GD, Martinez CM, Ysrraelit MC. Selection of disease modifying therapies in multiple sclerosis based on patient's age and disease activity: Data from a nationwide registry. J Neurol Sci 2024; 461:123052. [PMID: 38797140 DOI: 10.1016/j.jns.2024.123052] [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: 10/22/2023] [Revised: 05/09/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Knowledge of the safety and efficacy of disease-modifying therapies (DMTs) in older patients with Multiple Sclerosis (pwMS) is limited due to their exclusion from clinical trials. Our purpose is to evaluate the choice of DMTs in pwMS older than 50 years old in a real-world setting. METHODS Cross-sectional study of pwMS from the Argentine MS and NMOSD Registry. We included patients under 35 and above 50 years old prescribed DMTs. Disease activity was categorized as highly active (HA) or not highly active (NHA), and DMTs were classified as low efficacy therapies (LET) or high efficacy therapies (HET). RESULTS 1460 patients (65% females) were enrolled. The HA group comprised 241 patients, 198 young (82.2%) and 43 older (17.8%). The NHA group included 1219 patients, 893 young (73%) and 326 older (27%). In the NHA group, older patients received LET more frequently than younger patients (66% versus 44%; p < 0.01). In the HA group, older patients received LET in 61% of cases, whereas younger patients received HET in 71% (p = 0.01). CONCLUSION The study shows the preference of LET in older patients regardless of disease activity. However it does not demonstrate a difference in disability in older patients based on low vs high efficacy DMTs used, probably due to the design of the study. Further longitudinal studies are warranted to address this issue.
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Affiliation(s)
| | - Jorge Correale
- Departamento de Neuroinmunología - FLENI, CABA, Argentina; Profesor honorario de la facultad de farmacia y bioquimica, Universidad de Buenos Aires, Argentina
| | - Marcela Fiol
- Departamento de Neuroinmunología - FLENI, CABA, Argentina
| | | | - Juan I Rojas
- Hospital Universitario de CEMIC, CABA, Argentina
| | - Marina Alonso
- Servicio de clínica médica, Hospital Italiano de Buenos Aires, CABA, Argentina
| | - Agustín Pappolla
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jimena Miguez
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Liliana Patrucco
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Leila Cohen
- Centro universitario de esclerosis múltiple (CUEM), Hospital Ramos Mejía, CABA, Argentina
| | - Ricardo Alonso
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía. / Servicio de neurología, Sanatorio Güemes, Argentina
| | - Berenice Silva
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires / Centro universitario de esclerosis múltiple (CUEM), Hospital Ramos Mejía, CABA, Argentina
| | | | - Norma Deri
- Centro de Especialidades Neurológicas y Rehabilitación (CENyR), Argentina
| | - Marcos Burgos
- Servicio de Neurología, Hospital San Bernardo, Salta, Argentina
| | | | - Raul Piedrabuena
- Clínica Universitaria Reina Fabiola, Córdoba, Instituto Lennox, Córdoba, Argentina
| | - Verónica Tkachuk
- Neuroinmunologia Hospital de Clínicas "José de san Martin", CABA, Argentina
| | - Andres Barboza
- Servicio de Neurología, Hospital Central Mendoza, Mendoza, Argentina
| | - Alejandra Martinez
- Sección de Enfermedades Desmielinizantes - Hospital Británico, CABA, Argentina
| | - Maria E Balbuena
- Neuroinmunologia Hospital de Clínicas "José de san Martin", CABA, Argentina
| | | | - Pedro Nofal
- Hospital de Clínicas Nuestra Señora del Carmen, San Miguel de Tucumán, Tucumán, Argentina
| | - Pablo A Lopez
- Neuroimmunology Unit, Department of Neurosciences, Hospital Alemán, Buenos Aires, Argentina
| | - Dario Tavolini
- INECO Neurociencias Oroño - Fundación INECO, Rosario, Santa Fe, Argentina
| | | | - Javier P Hryb
- Neuroinmunología Clínica y Enfermedades Desmielinizantes. Hospital Carlos G Durand, CABA, Argentina
| | | | - Luciano Recchia
- Servicio de Neurología, Hospital Central Mendoza, Mendoza, Argentina
| | | | | | | | - Fatima Pagani
- Instituto de Neurociencias Fundación Favaloro, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | - Maria C Curbelo
- Sección de Enfermedades Desmielinizantes - Hospital Británico, CABA, Argentina
| | | | | | | | - Juan P Pettinicchi
- Neuroimmunology Unit, Department of Neurosciences, Hospital Alemán, Buenos Aires, Argentina
| | - Adriana Carra
- Sección de Enfermedades Desmielinizantes - Hospital Británico, CABA, Argentina
| | - Gustavo Jose
- Clínica San Jorge, Ushuaia, Tierra del fuego, Argentina
| | | | - Santiago Bestoso
- Servicio de Neurología - Hospital Escuela José F. de San Martín Corrientes, Corrientes, Argentina
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Lepore V, Paletta P, Bosetti C, Santucci C, Ponzio M, Pupillo E, Leone MA, Bergamaschi R, Mosconi P. Temporal and spatial patterns in the prescriptions of disease-modifying therapies for multiple sclerosis. Results from the Italian Multiple Sclerosis and Related Disorders Register. Mult Scler Relat Disord 2024; 87:105638. [PMID: 38713966 DOI: 10.1016/j.msard.2024.105638] [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: 10/02/2023] [Revised: 02/02/2024] [Accepted: 04/18/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND The therapeutic scenario in multiple sclerosis (MS) has evolved over recent years with the progressive introduction of new drugs focused to better balance efficacy, safety and management requirements. The objective of this study was to examine the prescribing patterns of disease-modifying therapies (DMT) over time and across different geographic areas, and the latency between disease onset, first Register center visit, disease diagnosis, and the start of treatment in a large cohort of persons with MS from the Italian Multiple Sclerosis and Related Disorders Register. METHODS Up to 2022, the Register collected data from 124 centers on more than 78,000 persons, of whom 56,872 received at least one DMT prescription. Beside baseline demographic and clinical characteristics, we focused on DMT according to their efficacy distinguishing between moderate-efficacy (ME), or high-efficacy (HE). RESULTS There was a higher probability of prescribing HE-DMT for increasing calendar years (multivariable odds ratio, OR=11.51 in 2021 or thereafter vs before 2000), in males (OR=1.08 vs females), patients with primary progressive with or without relapse (OR=3.00 vs clinically isolated syndrome), those with a higher Expanded Disability Status Scale score (OR=3.85 for >4 versus 0-1), and those from larger referral centers (OR=1.89 vs smaller ones). Conversely, higher age at onset was associated to a lower probability of prescribing HE-DMT (OR=0.74 at 40 or more vs <20 years). A trend to shorter times was observed in subsequent calendar years for disease onset, first center visit, diagnosis and first DMT prescription. No trend was detected based on the location of the geographic referral centers. The times between disease onset, first center visit, and diagnosis and the first DMT prescription showed significant decreases according to the year, while differences were less evident for the geographic areas. CONCLUSION This study highlights some factors influencing the choice of HE-DMT, including aspects of both healthcare and clinical phenotype. The absence of a geographic pattern may indicate some homogeneity in DMT prescriptions across different Italian MS centers.
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Affiliation(s)
- Vito Lepore
- Dipartimento di Epidemiologia Medica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy
| | - Pasquale Paletta
- Dipartimento di Epidemiologia Medica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy
| | - Cristina Bosetti
- Dipartimento di Epidemiologia Medica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy
| | - Claudia Santucci
- Dipartimento di Epidemiologia Medica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy; Department of Clinical Sciences and Community Health, University of Milan, Via Giovanni Celoria 22, 20133 Milano, Italy
| | - Michela Ponzio
- Scientific Research Area, Italian Multiple Sclerosis Foundation, Via Operai 40, 16149 Genova, Italy
| | - Elisabetta Pupillo
- Dipartimento di Neuroscienze, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy
| | - Maurizio A Leone
- Dipartimento di Neuroscienze, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy
| | - Roberto Bergamaschi
- Centro Sclerosi Multipla, IRCCS Fondazione Mondino, Via Mondino 2, 27100 Pavia, Italy
| | - Paola Mosconi
- Dipartimento di Epidemiologia Medica, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri 2, 20156 Milano, Italy.
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Warszawer Y, Gurevich M, Kerpel A, Dreyer Alster S, Nissan Y, Shirbint E, Hoffmann C, Achiron A. Mapping brain volume change across time in primary-progressive multiple sclerosis. Neuroradiology 2024:10.1007/s00234-024-03354-7. [PMID: 38609687 DOI: 10.1007/s00234-024-03354-7] [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: 02/20/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024]
Abstract
PURPOSE Detection and prediction of the rate of brain volume loss with age is a significant unmet need in patients with primary progressive multiple sclerosis (PPMS). In this study we construct detailed brain volume maps for PPMS patients. These maps compare age-related changes in both cortical and sub-cortical regions with those in healthy individuals. METHODS We conducted retrospective analyses of brain volume using T1-weighted Magnetic Resonance Imaging (MRI) scans of a large cohort of PPMS patients and healthy subjects. The volume of brain parenchyma (BP), cortex, white matter (WM), deep gray matter, thalamus, and cerebellum were measured using the robust SynthSeg segmentation tool. Age- and gender-related regression curves were constructed based on data from healthy subjects, with the 95% prediction interval adopted as the normality threshold for each brain region. RESULTS We analyzed 495 MRI scans from 169 PPMS patients, aged 20-79 years, alongside 563 exams from healthy subjects aged 20-86. Compared to healthy subjects, a higher proportion of PPMS patients showed lower than expected brain volumes in all regions except the cerebellum. The most affected areas were BP, WM, and thalamus. Lower brain volumes correlated with longer disease duration for BP and WM, and higher disability for BP, WM, cortex, and thalamus. CONCLUSIONS Constructing age- and gender-related brain volume maps enabled identifying PPMS patients at a higher risk of brain volume loss. Monitoring these high-risk patients may lead to better treatment decisions and improve patient outcomes.
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Affiliation(s)
- Yehuda Warszawer
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel.
- Arrow Program for Medical Research Education, Sheba Medical Center, Ramat-Gan, Israel.
- Adelson School of Medicine, Ariel University, Ariel, Israel.
| | - Michael Gurevich
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Kerpel
- Department of Radiology, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Yael Nissan
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Emanuel Shirbint
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Chen Hoffmann
- Department of Radiology, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Achiron
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Carlson AK, Fox RJ. Pathophysiology, Diagnosis, Treatment and Emerging Neurotherapeutic Targets for Progressive Multiple Sclerosis: The Age of PIRA. Neurol Clin 2024; 42:39-54. [PMID: 37980122 DOI: 10.1016/j.ncl.2023.07.002] [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: 11/20/2023]
Abstract
More than one million individuals are impacted by progressive forms of multiple sclerosis. The literature examining the management of MS has focused primarily on relapsing forms of disease, and effective therapies targeting progressive mechanisms in MS remains a significant unmet need. Despite this, there are several encouraging potential therapeutics on the horizon. Improved understanding of mechanisms underlying MS progression, identification and validation of biomarkers, identification of novel therapeutic targets, and improved trial design are needed to further propel progress in the management of individuals with progressive forms of MS.
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Affiliation(s)
- Alise K Carlson
- Cleveland Clinic Mellen Center, 9500 Euclid Avenue U10, Cleveland, OH 44195, USA
| | - Robert J Fox
- Cleveland Clinic Mellen Center, 9500 Euclid Avenue U10, Cleveland, OH 44195, USA.
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Siddiqui A, Yang JH, Hua LH, Graves JS. Clinical and Treatment Considerations for the Pediatric and Aging Patients with Multiple Sclerosis. Neurol Clin 2024; 42:255-274. [PMID: 37980118 DOI: 10.1016/j.ncl.2023.07.003] [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: 11/20/2023]
Abstract
Chronologic aging is associated with multiple pathologic and immunologic changes that impact the clinical course of multiple sclerosis (MS). Clinical phenotypes evolve across the lifespan, from a highly inflammatory course in the very young to a predominantly neurodegenerative phenotype in older patients. Thus, unique clinical considerations arise for the diagnosis and management of the two age extremes of pediatric and geriatric MS populations. This review covers epidemiology, diagnosis, and treatment strategies for these populations with nuanced discussions on therapeutic approaches to effectively care for patients living with MS at critical transition points during their lifespan.
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Affiliation(s)
- Areeba Siddiqui
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W. Bonneville Avenue, Las Vegas, NV 89106, USA
| | - Jennifer H Yang
- Department of Neurosciences, University of California San Diego, 9500 Gilman Drive, Mail Code 0662, La Jolla, CA 92093, USA; Division of Pediatric Neurology, Rady Children's Hospital, 3020 Children's Way MC 5009, San Diego, CA 92123, USA
| | - Le H Hua
- Cleveland Clinic Lou Ruvo Center for Brain Health, 888 W. Bonneville Avenue, Las Vegas, NV 89106, USA.
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, 9500 Gilman Drive, Mail Code 0662, La Jolla, CA 92093, USA; Division of Pediatric Neurology, Rady Children's Hospital, 3020 Children's Way MC 5009, San Diego, CA 92123, USA
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Houtchens M, Howard D. Ocrelizumab in highly disabled progressive multiple sclerosis patients. Mult Scler Relat Disord 2024; 82:105345. [PMID: 38181693 DOI: 10.1016/j.msard.2023.105345] [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] [Received: 06/09/2023] [Revised: 11/10/2023] [Accepted: 11/24/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Ocrelizumab is a commonly used anti-CD20 monoclonal antibody with efficacy in the treatment of both relapsing-remitting (RRMS) and primary progressive (PPMS) multiple sclerosis. Real world use of ocrelizumab in MS patients with higher levels of motor disability requiring a walker or a wheelchair is not well characterized as these populations were excluded from initial studies. Higher levels of disability may be a barrier to treatment access. This study aimed to describe the access to, and tolerability and therapeutic outcomes of ocrelizumab in highly disabled MS patients in a real-world setting. METHODS As part of an ongoing study of ocrelizumab treatment access, barriers, and outcomes in MS patients at the Brigham MS Center, we retrospectively reviewed all patients with an Expanded Disability Status Scale (EDSS) of 6.5 or greater at the time of ocrelizumab initiation. All patients were started on ocrelizumab by their treating providers prior to this study initiation. Patients were excluded for recent rituximab exposure, co-treatment with more than one immunosuppressant, or alternative diagnoses contributing to high EDSS. Data was collected on incidence and severity of side effects while on ocrelizumab, persistence of treatment beyond one year, and MS stabilization versus progression while on this treatment. RESULTS Of the 1219 patients on ocrelizumab between 2017 and 2021, 113 (9.3 %) had EDSS of 6.5 or greater at the time of ocrelizumab initiation. Of the 113, 51 (45.1 %) were excluded: 6 (5.3 %) because they were duplicates or didn't receive ocrelizumab at our center, 25 (22.1 %) due to rituximab treatment in the previous year, 16 (14.2 %) due to lack of at least 1 year of follow up, and 4 (3.5 %) due to relevant comorbidities/treatment with other immunosuppressants. 62 patients were included in the final analysis. At ocrelizumab start, mean age was 62.1 +/- 8.7 years and median EDSS was 7.0 (range 6.5 to 9.5). Ocrelizumab was started in 26 of the included 62 patients (41.9 %) because of objective clinical disease worsening, in 17 (27.4 %) because of subjective worsening, in 8 (12.9 %) to prevent future progression. 32 patients (51.6 %) continued ocrelizumab throughout the study period, with average length of ocrelizumab use of 36.5 +/- 17.0 months. 29 patients (46.8 %) experienced no side effects during the study period. 29 (46.7 %) patients discontinued treatment, and of those, 9 (31.0 %) cited more than one reason for discontinuation: 17 (58.6 %) cited side effects, 12 (41.4 %) cited progression/lack of benefit, 6 (20.7 %) cited the Covid19 pandemic, and 1 (3.4 %) cited financial issues as a reason for discontinuation. Over the course of the study, 16 (25.8 %) patients had disability worsening by EDSS, 5 (8.1 %) had disability improvement, and 41 (66.1 %) remained stable, with a median end EDSS of 7.0 (range 6.5 to 9.5). Importantly, 18 patients (29.0 %) reported subjective disease stability while on ocrelizumab. CONCLUSIONS Ocrelizumab may lead to disease stabilization in a subset of highly disabled MS patients, but possible benefits need to be carefully balanced against the incidence of adverse events in this high-risk patient population.
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Affiliation(s)
- Maria Houtchens
- Neurology Department, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA 02115, USA.
| | - Danielle Howard
- Neurology Department, Brigham and Women's Hospital, 60 Fenwood Rd, Boston, MA 02115, USA
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Gakis G, Angelopoulos I, Panagoulias I, Mouzaki A. Current knowledge on multiple sclerosis pathophysiology, disability progression assessment and treatment options, and the role of autologous hematopoietic stem cell transplantation. Autoimmun Rev 2024; 23:103480. [PMID: 38008300 DOI: 10.1016/j.autrev.2023.103480] [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] [Received: 10/31/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) that affects nearly 2.8 million people each year. MS distinguishes three main types: relapsing-remitting MS (RRMS), secondary progressive MS (SPMS) and primary progressive MS (PPMS). RRMS is the most common type, with the majority of patients eventually progressing to SPMS, in which neurological development is constant, whereas PPMS is characterized by a progressive course from disease onset. New or additional insights into the role of effector and regulatory cells of the immune and CNS systems, Epstein-Barr virus (EBV) infection, and the microbiome in the pathophysiology of MS have emerged, which may lead to the development of more targeted therapies that can halt or reverse neurodegeneration. Depending on the type and severity of the disease, various disease-modifying therapies (DMTs) are currently used for RRMS/SPMS and PPMS. As a last resort, and especially in highly active RRMS that does not respond to DMTs, autologous hematopoietic stem cell transplantation (AHSCT) is performed and has shown good results in reducing neuroinflammation. Nevertheless, the question of its potential role in preventing disability progression remains open. The aim of this review is to provide a comprehensive update on MS pathophysiology, assessment of MS disability progression and current treatments, and to examine the potential role of AHSCT in preventing disability progression.
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Affiliation(s)
- Georgios Gakis
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece
| | - Ioannis Angelopoulos
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece
| | - Ioannis Panagoulias
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece
| | - Athanasia Mouzaki
- Laboratory of Immunohematology, Medical School, University of Patras, Patras, Greece.
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Jakimovski D, Bittner S, Zivadinov R, Morrow SA, Benedict RH, Zipp F, Weinstock-Guttman B. Multiple sclerosis. Lancet 2024; 403:183-202. [PMID: 37949093 DOI: 10.1016/s0140-6736(23)01473-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 06/08/2023] [Accepted: 07/12/2023] [Indexed: 11/12/2023]
Abstract
Multiple sclerosis remains one of the most common causes of neurological disability in the young adult population (aged 18-40 years). Novel pathophysiological findings underline the importance of the interaction between genetics and environment. Improvements in diagnostic criteria, harmonised guidelines for MRI, and globalised treatment recommendations have led to more accurate diagnosis and an earlier start of effective immunomodulatory treatment than previously. Understanding and capturing the long prodromal multiple sclerosis period would further improve diagnostic abilities and thus treatment initiation, eventually improving long-term disease outcomes. The large portfolio of currently available medications paved the way for personalised therapeutic strategies that will balance safety and effectiveness. Incorporation of cognitive interventions, lifestyle recommendations, and management of non-neurological comorbidities could further improve quality of life and outcomes. Future challenges include the development of medications that successfully target the neurodegenerative aspect of the disease and creation of sensitive imaging and fluid biomarkers that can effectively predict and monitor disease changes.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA; Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Stefan Bittner
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA; Center for Biomedical Imaging at the Clinical Translational Science Institute, State University of New York at Buffalo, Buffalo, NY, USA
| | - Sarah A Morrow
- Department of Clinical Neurological Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Ralph Hb Benedict
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Frauke Zipp
- Department of Neurology, Focus Program Translational Neuroscience and Immunotherapy, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
| | - Bianca Weinstock-Guttman
- Jacobs Comprehensive MS Treatment and Research Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
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Inojosa H, Ziemssen T. [Current and innovative Approaches to Multiple Sclerosis Therapy]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2024; 92:41-60. [PMID: 38272020 DOI: 10.1055/a-2167-1391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
The landscape of immunotherapies in the management of Multiple Sclerosis (MS) is currently particularly dynamic. Over 21 immunotherapeutic options are approved by the European Meidcines Agency (EMA), Food and Drug Administration (FDA) and newer approaches are ongoing in clinical trials. With advancements in the understanding of MS pathophysiology and further development of diagnosis criteria, newer and more specific disease-modifying therapies (DMTs) have emerged in recent years. The selection and timing of proper therapeutic approaches is increasingly complex. We provide an overview of the available immunotherapies for a personalized MS treatment and discuss practical insights into their application. The importance of early intervention, distinction between escalation and induction approaches, and consideration of high-efficacy treatments for specific patient groups are in discussed. We emphasize the significance of a patient-centered approach, taking into account various factors such as comorbidities, family planning, administration preferences and potential side effects in treatment decision-making.
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Gopal A, Torres WO, Winawer I, Poole S, Balan A, Stuart HS, Fritz NE, Gelfand JM, Allen DD, Bove R. "Self-care selfies": Patient-uploaded videos capture meaningful changes in dexterity over 6 months. Ann Clin Transl Neurol 2023; 10:2394-2406. [PMID: 37877622 PMCID: PMC10723247 DOI: 10.1002/acn3.51928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/26/2023] Open
Abstract
OBJECTIVE Upper extremity function reflects disease progression in multiple sclerosis (MS). This study evaluated the feasibility, validity, and sensitivity to change of remote dexterity assessments applying human pose estimation to patient-uploaded videos. METHODS A discovery cohort of 50 adults with MS recorded "selfie" videos of self-care tasks at home: buttoning, brushing teeth, and eating. Kinematic data were extracted using MediaPipe Hand pose estimation software. Clinical comparison tests were grip and pinch strength, 9 hole peg test (9HPT), and vibration, and patient-reported dexterity assessments (ABILHAND). Feasibility and acceptability were evaluated (Health-ITUES framework). A validation cohort (N = 35) completed 9HPT and videos. RESULTS The modality was feasible: 88% of the 50 enrolled participants uploaded ≥3 videos, and 74% completed the study. It was also usable: assessments easy to access (95%), platform easy to use (97%), and tasks representative of daily activities (86%). The buttoning task revealed four metrics with strong correlations with 9HPT (nondominant: r = 0.60-0.69, dominant: r = 0.51-0.57, P < 0.05) and ABILHAND (r = -0.48, P = 0.05). Retest validity at 1 week was stable (r > 0.8). Cross-sectional correlations between video metrics and 9HPT were similar at 6 months, and in the validation cohort (nondominant: r = 0.46, dominant: r = 0.45, P < 0.05). Over 6 months, pinch strength (5.8-5.0 kg/cm2 , P = 0.05) and self-reported pinch (ABILHAND) decreased marginally. While only 15% of participants worsened by 20% on 9HPT, 70% worsened in key buttoning video metrics. INTERPRETATION Patient-uploaded videos represent a novel, patient-centered modality for capturing dexterity that appears valid and sensitive to change, enhancing its potential to be disseminated for neurological disease monitoring and treatment.
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Affiliation(s)
- Arpita Gopal
- Department of NeurologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Wilson O. Torres
- Department of Mechanical EngineeringUniversity of CaliforniaBerkeleyCaliforniaUSA
| | - Ilana Winawer
- Department of Physical Therapy and Rehabilitation SciencesUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Shane Poole
- Department of NeurologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Ayushi Balan
- Department of NeurologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Hannah S. Stuart
- Department of Mechanical EngineeringUniversity of CaliforniaBerkeleyCaliforniaUSA
| | - Nora E. Fritz
- Department of Neurology and Program of Physical TherapyWayne State UniversityDetroitMichiganUSA
| | - Jeffrey M. Gelfand
- Department of NeurologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Diane D. Allen
- Department of Physical Therapy and Rehabilitation SciencesUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Riley Bove
- Department of NeurologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
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11
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Alonso-Moreno M, Ladrón-Guevara M, Ciudad-Gutiérrez P. Systematic review of gender bias in clinical trials of monoclonal antibodies for the treatment of multiple sclerosis. Neurologia 2023; 38:695-706. [PMID: 37996214 DOI: 10.1016/j.nrleng.2021.01.008] [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] [Received: 10/21/2020] [Accepted: 01/01/2021] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION This article analyses the presence of gender bias in clinical trials of monoclonal antibodies used to treat multiple sclerosis. MATERIAL AND METHODS We performed a systematic review of controlled clinical trials of 4 monoclonal antibodies used to treat multiple sclerosis (natalizumab, rituximab, alemtuzumab, and ocrelizumab). We searched the PubMed/MEDLINE database for articles published in English before March 2020. The study was conducted in accordance with the relevant international recommendations. RESULTS The search identified 89 articles, 55 of which met the inclusion criteria. Of all patients included in these trials, 64.6% were women. The lead authors of 10 of the studies were women. Fifteen of the 55 studies included a sex-based analysis of the primary endpoint. Only 8 articles discussed the results separately for men and for women. CONCLUSIONS The clinical trials of these 4 monoclonal antibodies present a significant gender bias. In most cases, the primary and secondary endpoints are not analyzed according to patient sex, despite the fact that international recommendations include this as a minimum requirement for ensuring scientific validity and obtaining appropriate results for extrapolation to the wider population.
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Affiliation(s)
- M Alonso-Moreno
- Pharmacy Service, Hospital Universitario Virgen del Rocío, Avenue Manuel Siurot, 41013 Seville, Spain.
| | - M Ladrón-Guevara
- Pharmacy Service, Hospital Universitario Virgen del Rocío, Avenue Manuel Siurot, 41013 Seville, Spain
| | - P Ciudad-Gutiérrez
- Pharmacy Service, Hospital Universitario Virgen del Rocío, Avenue Manuel Siurot, 41013 Seville, Spain
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12
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Capasso N, Virgilio E, Covelli A, Giovannini B, Foschi M, Montini F, Nasello M, Nilo A, Prestipino E, Schirò G, Sperandei S, Clerico M, Lanzillo R. Aging in multiple sclerosis: from childhood to old age, etiopathogenesis, and unmet needs: a narrative review. Front Neurol 2023; 14:1207617. [PMID: 37332984 PMCID: PMC10272733 DOI: 10.3389/fneur.2023.1207617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/15/2023] [Indexed: 06/20/2023] Open
Abstract
Multiple sclerosis (MS) primarily affects adult females. However, in the last decades, rising incidence and prevalence have been observed for demographic extremes, such as pediatric-onset MS (POMS; occurring before 18 years of age) and late-onset MS (corresponding to an onset above 50 years). These categories show peculiar clinical-pathogenetic characteristics, aging processes and disease courses, therapeutic options, and unmet needs. Nonetheless, several open questions are still pending. POMS patients display an important contribution of multiple genetic and environmental factors such as EBV, while in LOMS, hormonal changes and pollution may represent disease triggers. In both categories, immunosenescence emerges as a pathogenic driver of the disease, particularly for LOMS. In both populations, patient and caregiver engagement are essential from the diagnosis communication to early treatment of disease-modifying therapy (DMTs), which in the elderly population appears more complex and less proven in terms of efficacy and safety. Digital technologies (e.g., exergames and e-training) have recently emerged with promising results, particularly in treating and following motor and cognitive deficits. However, this offer seems more feasible for POMS, being LOMS less familiar with digital technology. In this narrative review, we discuss how the aging process influences the pathogenesis, disease course, and therapeutic options of both POMS and LOMS. Finally, we evaluate the impact of new digital communication tools, which greatly interest the current and future management of POMS and LOMS patients.
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Affiliation(s)
- Nicola Capasso
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
| | - Eleonora Virgilio
- Neurology Unit, Department of Translational Medicine, AOU Maggiore della Carità Novara, University of Eastern Piedmont, Novara, Italy
| | - Antonio Covelli
- Department of Neurology, Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Beatrice Giovannini
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Matteo Foschi
- Department of Neuroscience, MS Center, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
- Department of Biotechnological and Applied Clinical Sciences (DISCAB), University of L’Aquila, L’Aquila, Italy
| | - Federico Montini
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Nasello
- Neurology Unit, Department of Neurosciences, Mental Health and Sensory organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Annacarmen Nilo
- Clinical Neurology Unit, Department of Head, Neck and Neurosciences, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Elio Prestipino
- UOSC Neuro-Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Giuseppe Schirò
- Section of Neurology, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Silvia Sperandei
- Section of Neurology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Roberta Lanzillo
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, Federico II University of Naples, Naples, Italy
- Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
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13
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Sabahi Z, Daei Sorkhabi A, Sarkesh A, Naseri A, Asghar-Rezaei N, Talebi M. A systematic review of the safety and efficacy of monoclonal antibodies for progressive multiple sclerosis. Int Immunopharmacol 2023; 120:110266. [PMID: 37209514 DOI: 10.1016/j.intimp.2023.110266] [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: 02/14/2023] [Revised: 04/17/2023] [Accepted: 04/28/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Progressive multiple sclerosis (PMS) is a debilitating condition characterized by progressively worsening symptoms. Monoclonal antibodies are novel therapies for MS, but their safety and efficacy in the progressive form have not been comprehensively studied. In this systematic review, we aimed to evaluate the available evidence regarding monoclonal antibody treatment for PMS. METHODS After registration of the study protocol in PROSPERO, we systematically searched three major databases for clinical trials involving monoclonal antibodies administration for PMS treatment. All the retrieved results were imported into the EndNote reference manager. After removing the duplicates, two independent researchers did the study selection and data extraction. The risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist. RESULTS Of the 1846 studies in the preliminary search, 13 clinical trials investigating monoclonal antibodies (Ocrelizumab, Natalizumab, Rituximab, and Alemtuzumab) in PMS patients were included. Ocrelizumab was significantly effective in reducing clinical disease progression measures in primary PMS patients. The results for Rituximab were not completely reassuring and only showed significant changes for some endpoints on MRI and clinical measures. Natalizumab decreased the relapse rate and improved MRI features for secondary PMS patients, but not clinical endpoints. The studies on Alemtuzumab treatment revealed conflicting outcomes, with improvements observed in MRI endpoints but clinical worsening in patients. Additionally, among the studied adverse events, upper respiratory infections, urinary tract infections, and nasopharyngitis were frequently reported. CONCLUSION Based on our findings, Ocrelizumab is the most efficient monoclonal antibody for primary PMS, although it is associated with a higher risk of infection. While other monoclonal antibodies did not show significant promise in treating PMS, more research is necessary.
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Affiliation(s)
- Zahra Sabahi
- Research Center for Evidence-Based Medicine, Iranian EBM Centre: A Joanna Briggs Institute (JBI) Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amin Daei Sorkhabi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Aila Sarkesh
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amirreza Naseri
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nazli Asghar-Rezaei
- Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahnaz Talebi
- Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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14
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Bühler A, Wolbers M, Model F, Wang Q, Belachew S, Manfrini M, Lorscheider J, Kappos L, Beyersmann J. Recurrent disability progression endpoints in multiple sclerosis clinical trials. Mult Scler 2023; 29:130-139. [PMID: 36177953 PMCID: PMC9896250 DOI: 10.1177/13524585221125382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The current standard endpoint to assess disability accumulation in multiple sclerosis (MS) clinical trials is the time to the first confirmed disability progression, which excludes subsequent progression events. Including recurrent progression events may permit a more comprehensive assessment of treatment effects on disability progression. OBJECTIVE To propose a definition of recurrent disability progression events and to compare time-to-first and recurrent event analysis. METHODS Recurrent disability progression events were defined by expanding the recommended first event definition. Marginal recurrent event methods (negative binomial model, Lin-Wei-Yang-Ying model) were compared with Cox regression in data from three randomized controlled trials in relapsing multiple sclerosis (RMS) and primary progressive multiple sclerosis (PPMS), and in simulated randomized controlled trial data. RESULTS The recurrent event analyses included a substantially larger number of progression events compared with the time-to-first-event analyses (+7.5% and +9.9% in the RMS trials and +22.7% in the PPMS trial). The increase in the number of events resulted in more precise treatment effect estimates and a corresponding gain in statistical power. CONCLUSION Our results support the use of recurrent event data analysis, especially in progressive MS trials, to improve estimates of treatment effects, increase statistical power, and better capture the clinically meaningful long-term disability progression experience.
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Affiliation(s)
| | | | | | - Qing Wang
- Q Wang F. Hoffmann-La Roche Ltd., Grenzacherstrasse 124, Basel CH-4070 Switzerland.
| | | | | | - Johannes Lorscheider
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Head, Spine and Neuromedicine, Clinical Research and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
| | - Ludwig Kappos
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), Departments of Head, Spine and Neuromedicine, Clinical Research and Biomedical Engineering, University Hospital, University of Basel, Basel, Switzerland
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15
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Younger DS. Multiple sclerosis: Motor dysfunction. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:119-147. [PMID: 37620066 DOI: 10.1016/b978-0-323-98817-9.00016-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Multiple sclerosis is a chronic neurological disease characterized by inflammation and degeneration within the central nervous system. Over the course of the disease, most MS patients successively accumulate inflammatory lesions, axonal damage, and diffuse CNS pathology, along with an increasing degree of motor disability. While the pharmacological approach to MS targets inflammation to decrease relapse rates and relieve symptoms, disease-modifying therapy and immunosuppressive medications may not prevent the accumulation of pathology in most patients leading to long-term motor disability. This has been met with recent interest in promoting plasticity-guided concepts, enhanced by neurophysiological and neuroimaging approaches to address the preservation of motor function.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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16
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Lehnert T, Röver C, Köpke S, Rio J, Chard D, Fittipaldo AV, Friede T, Heesen C, Rahn AC. Immunotherapy for people with clinically isolated syndrome or relapsing-remitting multiple sclerosis: treatment response by demographic, clinical, and biomarker subgroups (PROMISE)-a systematic review protocol. Syst Rev 2022; 11:134. [PMID: 35778721 PMCID: PMC9250266 DOI: 10.1186/s13643-022-01997-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 05/28/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Multiple sclerosis (MS) is an inflammatory and degenerative disease of the central nervous system with an increasing worldwide prevalence. Since 1993, more than 15 disease-modifying immunotherapies (DMTs) have been licenced and have shown moderate efficacy in clinical trials. Based on the heterogeneity of the disease and the partial effectiveness of therapies, a personalised medicine approach would be valuable taking individual prognosis and suitability of a chosen therapy into account to gain the best possible treatment effect. The primary objective of this review is to assess the differential treatment effects of all approved DMTs in subgroups of adults with clinically isolated syndrome or relapsing forms of MS. We will analyse possible treatment effect modifiers (TEM) defined by baseline demographic characteristics (gender, age), and diagnostic (i.e. MRI measures) and clinical (i.e. relapses, disability level) measures of MS disease activity. METHODS We will include all published and accessible unpublished primary and secondary analyses of randomised controlled trials (RCTs) with a follow-up of at least 12 months investigating the efficacy of at least one approved DMT, with placebo or other approved DMTs as control intervention(s) in subgroups of trial participants. As the primary outcome, we will address disability as defined by the Expanded Disability Status Scale or multiple sclerosis functional composite scores followed by relapse frequency, quality of life measures, and side effects. MRI data will be analysed as secondary outcomes. MEDLINE, EMBASE, CINAHL, LILACS, CENTRAL and major trial registers will be searched for suitable studies. Titles and abstracts and full texts will be screened by two persons independently using Covidence. The risk of bias will be analysed based on the Cochrane "Risk of Bias 2" tool, and the certainty of evidence will be assessed using GRADE. Treatment effects will be reported as rate ratio or odds ratio. Primary analyses will follow the intention-to-treat principle. Meta-analyses will be carried out using random-effects models. DISCUSSION Given that individual patient data from clinical studies are often not available, the review will allow to analyse the evidence on TEM in MS immunotherapy and thus support clinical decision making in individual cases. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021279665 .
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Affiliation(s)
- Thomas Lehnert
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Christian Röver
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Sascha Köpke
- Institute of Nursing Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jordi Rio
- Neurology/Neuroimmunology, Centre d'Esclerosi Multiple de Catalunya (Cemcat), Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Declan Chard
- Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,National Institute for Health Research (NIHR), University College London Hospitals (UCLH) Biomedical Research Centre, London, UK
| | - Andrea V Fittipaldo
- Department of Oncology, Istituto Ricerche Farmacologiche "Mario Negri" IRCCS, Milano, Italy
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Christoph Heesen
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Anne C Rahn
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany. .,Institute for Social Medicine and Epidemiology, Nursing Research Unit, University of Lübeck, Lübeck, Germany.
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17
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Quantification of upper limb dysfunction in the activities of the daily living in persons with multiple sclerosis. Mult Scler Relat Disord 2022; 63:103917. [PMID: 35671673 DOI: 10.1016/j.msard.2022.103917] [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: 12/14/2021] [Revised: 05/12/2022] [Accepted: 05/26/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Dysfunction in upper limb (UL) function has been reported as an important indicator for disease progression in persons with multiple sclerosis (PwMS), thus a relevant outcome in clinical trials. However, standard assessment of UL function is limited to Nine-Hole Peg Test (NHPT) which assesses fine dexterity. This study aimed to deeply endophenotype UL involvement in PwMS and identify the most accurate set of measures needed to capture the complexity of UL dysfunction in the activities of daily living (ADL). METHODS 257 PwMS underwent an extensive UL assessment using standardized measures of grip strength and endurance, coordination, vibratory and tactile sensation, dexterity, capacity and functionality. Limitation in ADL was defined from an objective perspective using a timed test (Test d'Evaluation de la performance des Membres Supérieurs des Personnes Âgées: TEMPA) and from a subjective perspective using a questionnaire (Disabilities of the Arm, Shoulder and Hand: DASH). Disease severity subgroups were compared utilizing the Kruskal-Wallis test and frequencies determined the prevalence of abnormal UL for each measure. The Jonckheere-Terpstra test compared tested variables with disease severity. Then Receiver operating characteristic (ROC) curve analysis was used to test the accuracy of each tested variable in defining abnormality in the TEMPA and DASH. Cut-off scores were calculated using the Youden index. The predictive value of various tests over TEMPA and DASH were tested using a linear regression analysis. RESULTS UL dysfunction was highly prevalent in all the modalities tested, even in participants with no/mild disability. Box and Block Test (BBT), finger-nose test (FNT), and NHPT were independently selected with ROC analyses as the most accurate measures in detecting abnormalities in TEMPA and DASH. In multivariate regression models, BBT and FNT, and NHPT all contributed to predicting TEMPA (adj. R2 0.795, P < 0.001), while only BBT and FNT predicted DASH. CONCLUSIONS UL dysfunction is highly prevalent in PwMS, even when global disability is mild. BBT and FNT are time-efficient and cost-effective measures that complement the NHPT for more precise monitoring of PwMS at all disease stages.
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18
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Abstract
BACKGROUND Ocrelizumab is a humanised anti-CD20 monoclonal antibody developed for the treatment of multiple sclerosis (MS). It was approved by the Food and Drug Administration (FDA) in March 2017 for using in adults with relapsing-remitting multiple sclerosis (RRMS) and primary progressive multiple sclerosis (PPMS). Ocrelizumab is the only disease-modifying therapy (DMT) approved for PPMS. In November 2017, the European Medicines Agency (EMA) also approved ocrelizumab as the first drug for people with early PPMS. Therefore, it is important to evaluate the benefits, harms, and tolerability of ocrelizumab in people with MS. OBJECTIVES To assess the benefits, harms, and tolerability of ocrelizumab in people with RRMS and PPMS. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, and two trials registers on 8 October 2021. We screened reference lists, contacted experts, and contacted the main authors of studies. SELECTION CRITERIA All randomised controlled trials (RCTs) involving adults diagnosed with RRMS or PPMS according to the McDonald criteria, comparing ocrelizumab alone or associated with other medications, at the approved dose of 600 mg every 24 weeks for any duration, versus placebo or any other active drug therapy. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS Four RCTs met our selection criteria. The overall population included 2551 participants; 1370 treated with ocrelizumab 600 mg and 1181 controls. Among the controls, 298 participants received placebo and 883 received interferon beta-1a. The treatment duration was 24 weeks in one study, 96 weeks in two studies, and at least 120 weeks in one study. One study was at high risk of allocation concealment and blinding of participants and personnel; all four studies were at high risk of bias for incomplete outcome data. For RRMS, compared with interferon beta-1a, ocrelizumab was associated with: 1. lower relapse rate (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.52 to 0.73; 2 studies, 1656 participants; moderate-certainty evidence); 2. a lower number of participants with disability progression (hazard ratio (HR) 0.60, 95% CI 0.43 to 0.84; 2 studies, 1656 participants; low-certainty evidence); 3. little to no difference in the number of participants with any adverse event (RR 1.00, 95% CI 0.96 to 1.04; 2 studies, 1651 participants; moderate-certainty evidence); 4. little to no difference in the number of participants with any serious adverse event (RR 0.79, 95% CI 0.57 to 1.11; 2 studies, 1651 participants; low-certainty evidence); 5. a lower number of participants experiencing treatment discontinuation caused by adverse events (RR 0.58, 95% CI 0.37 to 0.91; 2 studies, 1651 participants; low-certainty evidence); 6. a lower number of participants with gadolinium-enhancing T1 lesions on magnetic resonance imaging (MRI) (RR 0.27, 95% CI 0.22 to 0.35; 2 studies, 1656 participants; low-certainty evidence); 7. a lower number of participants with new or enlarging T2-hyperintense lesions on MRI (RR 0.63, 95% CI 0.57 to 0.69; 2 studies, 1656 participants; low-certainty evidence) at 96 weeks. For PPMS, compared with placebo, ocrelizumab was associated with: 1. a lower number of participants with disability progression (HR 0.75, 95% CI 0.58 to 0.98; 1 study, 731 participants; low-certainty evidence); 2. a higher number of participants with any adverse events (RR 1.06, 95% CI 1.01 to 1.11; 1 study, 725 participants; moderate-certainty evidence); 3. little to no difference in the number of participants with any serious adverse event (RR 0.92, 95% CI 0.68 to 1.23; 1 study, 725 participants; low-certainty evidence); 4. little to no difference in the number of participants experiencing treatment discontinuation caused by adverse events (RR 1.23, 95% CI 0.55 to 2.75; 1 study, 725 participants; low-certainty evidence) for at least 120 weeks. There were no data for number of participants with gadolinium-enhancing T1 lesions on MRI and number of participants with new or enlarging T2-hyperintense lesions on MRI. AUTHORS' CONCLUSIONS For people with RRMS, ocrelizumab probably results in a large reduction in relapse rate and little to no difference in adverse events when compared with interferon beta-1a at 96 weeks (moderate-certainty evidence). Ocrelizumab may result in a large reduction in disability progression, treatment discontinuation caused by adverse events, number of participants with gadolinium-enhancing T1 lesions on MRI, and number of participants with new or enlarging T2-hyperintense lesions on MRI, and may result in little to no difference in serious adverse events (low-certainty evidence). For people with PPMS, ocrelizumab probably results in a higher rate of adverse events when compared with placebo for at least 120 weeks (moderate-certainty evidence). Ocrelizumab may result in a reduction in disability progression and little to no difference in serious adverse events and treatment discontinuation caused by adverse events (low-certainty evidence). Ocrelizumab was well tolerated clinically; the most common adverse events were infusion-related reactions and nasopharyngitis, and urinary tract and upper respiratory tract infections.
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Affiliation(s)
- Mengbing Lin
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jian Zhang
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yueling Zhang
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Jiefeng Luo
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shengliang Shi
- Department of Neurology, Second Affiliated Hospital of Guangxi Medical University, Nanning, China
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19
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Dubbioso R, Bove M, Boccia D, D'Ambrosio V, Nolano M, Manganelli F, Iodice R. Neurophysiological and behavioural correlates of ocrelizumab therapy on manual dexterity in patients with primary progressive multiple sclerosis. J Neurol 2022; 269:4791-4801. [PMID: 35419681 PMCID: PMC9363320 DOI: 10.1007/s00415-022-11114-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 12/20/2022]
Abstract
Background Hand dexterity impairment is a key feature of disability in people with primary progressive multiple sclerosis (PPMS). So far, ocrelizumab, a recombinant humanized monoclonal antibody that selectively depletes CD20-expressing B cells, is the only therapy approved for PPMS and recent analysis reported its ability to reduce the risk of upper limb disability progression. However, the neural mechanisms underlying hand impairment in PPMS and the brain networks behind the effect of ocrelizumab on manual dexterity are not fully understood. Objective Main aims of our study were: (i) to investigate neurophysiological and behavioural correlates of hand function impairment in subjects with PPMS, and (ii) to use neurophysiologic and behavioural measures to track the effects of ocrelizumab therapy on manual dexterity. Methods Seventeen PPMS patients and 17 healthy-controls underwent routine neurophysiological protocols assessing the integrity of cortico-spinal and somatosensory pathways and advanced transcranial magnetic stimulation (TMS) protocols evaluating inhibitory (short and long interval intracortical inhibition, short-latency afferent inhibition) and facilitatory (motor thresholds, intracortical facilitation, short-interval intracortical facilitation) circuits in the primary motor cortex. All subjects also underwent behavioural analysis of hand dexterity by means of nine-hole peg test and finger movement analysis, and hand strength with handgrip and three-point pinch test. Neurophysiological and clinical assessments of hand functionality were also performed after 1 year of ocrelizumab therapy. Results At baseline PPMS patients displayed a significant impairment of hand dexterity and strength compared to healthy controls (all p < 0.03). Neurophysiological study disclosed prolonged latencies of standard somatosensory and motor evoked potentials (all p < 0.025) and an overall reduction of intracortical excitability at TMS protocols, involving both excitatory and inhibitory circuits. Importantly, hand dexterity impairment, indexed by delayed 9HPT, correlated with TMS protocols investigating cortical sensorimotor integration (short-latency afferent inhibition, SAI), p = 0.009. Both parameters, 9HPT (p = 0.01) and SAI (p = 0.01), displayed a significant improvement after 1 year of therapy with ocrelizumab. Conclusion Intracortical sensorimotor networks are involved in hand dexterity dysfunction of PPMS. Ocrelizumab therapy displays a beneficial effect on hand dexterity impairment most likely through intracortical networks implicated in fast sensorimotor integration.
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Affiliation(s)
- Raffaele Dubbioso
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Via Sergio Pansini, 5. 80131, Napoli, Italy.
| | - Marco Bove
- IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Section of Human Physiology, Department of Experimental Medicine, Università Degli Studi Di Genova, 16132, Genoa, Italy
| | - Daniele Boccia
- IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Neuroscience Genetics, Maternal and Child Health (DINOGMI)Center of Excellence for Biomedical Research (CEBR), University of Genoa, RehabilitationGenoa, Ophthalmology, Italy
| | - Vincenzo D'Ambrosio
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Maria Nolano
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Via Sergio Pansini, 5. 80131, Napoli, Italy.,Department of Neurology, Istituti Clinici Scientifici Maugeri IRCCS, 27100, Pavia, Italy
| | - Fiore Manganelli
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Via Sergio Pansini, 5. 80131, Napoli, Italy
| | - Rosa Iodice
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Via Sergio Pansini, 5. 80131, Napoli, Italy
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Saposnik G, Andhavarapu S, Fernández Ó, Kim HJ, Wiendl H, Foss M, Zuo F, Havrdová EK, Celius E, Caceres F, Magyari M, Bermel R, Costa A, Terzaghi M, Kalincik T, Popescu V, Amato MP, Montalban X, Oh J. Factors associated with treatment escalation among MS specialists and general neurologists: Results from an International cojoint study. Mult Scler Relat Disord 2022; 58:103404. [PMID: 35216786 DOI: 10.1016/j.msard.2021.103404] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 10/19/2021] [Accepted: 11/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies in multiple sclerosis (MS) showed that therapeutic inertia (TI) affects 60-90% of neurologists and up to 25% of daily treatment decisions. The objective of this study was to determine the most common factors and attribute levels associated with decisions to treatment escalation in an international study in MS care. METHODS 300 neurologists with MS expertise from 20 countries were invited to participate. Participants were presented with 12 pairs of simulated MS patient profiles described by 13 clinically relevant factors. We used disaggregated discrete choice experiments to estimate the weight of factors and attributes affecting physicians' decisions when considering treatment selection. Participants were asked to select the ideal candidate for treatment escalation from modest to higher-efficacy therapies. RESULTS Overall, 229 neurologists completed the study (completion rate: 76.3%). The top 3 weighted factors associated with treatment escalation were: previous relapses (20%), baseline expanded disability status scale [EDSS] (18%), and MRI activity (13%). Patient demographics and desire for pregnancy had a modest influence (≤ 3%). We observed differences in the weight of factors associated with treatment escalation between MS specialists and non-MS specialists. CONCLUSIONS Our results provide critical information on factors influencing neurologists' treatment decisions and should be applied to continuing medical education strategies.
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Affiliation(s)
- G Saposnik
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, 55 Queen St E, Toronto, Ontario M5C 1R6, Canada; Director and Founder, NeuroEconSolutions© (www.neuroeconsolutions.com), Toronto, Canada; Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada.
| | - S Andhavarapu
- Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Ó Fernández
- Department of Pharmacology, Faculty of Medicine, University of Malaga, Institute of Biomedical Research of Malaga, Regional University Hospital of Malaga, Spain
| | - H J Kim
- Department of Neurology, Research Institute and Hospital of National Cancer Center, Goyang, Republic of Korea
| | - H Wiendl
- Department of Neurology, Institute of Translational Neurology, University of Münster, Germany
| | - M Foss
- Bootstrap Analytics, Calgary, Canada
| | - F Zuo
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
| | - E K Havrdová
- Department of Neurology, First Medical Faculty, Center for Clinical Neuroscience, Charles University, Prague, Czech Republic
| | - E Celius
- Department of Neurology, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - F Caceres
- Institute of Restorative Neurosciences, Buenos Aires, Argentina
| | - M Magyari
- Danish Multiple Sclerosis Center, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - R Bermel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, United States
| | - A Costa
- Neurology Department, Faculty of Medicine University of Porto, Centro Hospitalar Universitário São João, Portugal
| | - M Terzaghi
- Clinical Outcomes and Decision Neuroscience Unit, St Michael's Hospital, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
| | - T Kalincik
- Department of Medicine, MS Centre, Royal Melbourne Hospital Core Unit, University of Melbourne, Melborne, Australia
| | - V Popescu
- University MS Centre, Noorderhart Hospital, Pelt, Belgium; Hasselt University, Hasselt, Belgium
| | - M P Amato
- Department of Neurofarba, IRCCS Fondazione Don Carlo Gnocchi, University of Florence, Florence, Italy
| | - X Montalban
- Department of Neurology, Hospital Vall d´Hebron, Centre d'Esclerosi Mútiple de Catalunya, Universitat Autonoma de Barcelona, Spain
| | - J Oh
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, 55 Queen St E, Toronto, Ontario M5C 1R6, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Canada
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Abstract
Ocrelizumab (Ocrevus®) is an intravenously administered, humanized anti-CD20 monoclonal antibody approved for the treatment of adults with relapsing forms of multiple sclerosis (RMS) or primary progressive multiple sclerosis (PPMS). The efficacy of ocrelizumab in reducing relapse rates and disease activity in patients with RMS was demonstrated in pivotal trials (versus interferon β-1a) and supporting single-arm studies in specific subpopulations. In patients with PPMS, ocrelizumab reduced measures of clinical and MRI progression relative to placebo. Clinical benefits were maintained over ≥ 7.5 study years of treatment. Ocrelizumab was generally well tolerated and no new safety signals have emerged with long-term use. Extensive (albeit short-term) real-world data pertaining to ocrelizumab is consistent with that from clinical trials. Ocrelizumab provides the convenience of short, half-yearly infusions. Ocrelizumab continues to represent a generally well-tolerated, high-efficacy disease-modifying therapy (DMT) for RMS and is a valuable treatment for delaying disease progression in patients with PPMS (for whom there are currently no other approved DMTs).
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Affiliation(s)
- Yvette N Lamb
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
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22
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Saini A, Zucker-Levin A, McMillan B, Kumar P, Donkers S, Levin MC. A Descriptive Correlational Study to Evaluate Three Measures of Assessing Upper Extremity Function in Individuals with Multiple Sclerosis. Mult Scler Int 2021; 2021:5588335. [PMID: 34258067 PMCID: PMC8257389 DOI: 10.1155/2021/5588335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/21/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Activities of daily living and quality of life (QOL) are hindered by upper extremity (UE) impairments experienced by individuals with multiple sclerosis (iMS). The Nine-Hole Peg Test (9-HPT) is most frequently used to measure UE function. However, it does not measure peoples' ability to perform routine tasks in daily life and may not be useful in iMS who cannot pick up the pegs utilized in the 9-HPT. Therefore, we evaluated three measures to explore a more comprehensive assessment of UE function: Upper Extremity Function Scale (UEFS), Action Research Arm Test (ARAT), and the 9-HPT. The objectives were to quantitatively assess the relationship between these measures of UE function, understand if the measures correlate with QOL as calculated by the MS Quality of Life-54 (MSQOL-54), and to determine differences in the measures based on employment status. METHODS 112 (79 female) iMS were prospectively recruited for this descriptive correlational study. Inclusion criteria were as follows: confirmed diagnosis of MS or clinically isolated syndrome, age ≥ 18 years, and ability to self-consent. All statistical analyses including Spearman's correlation coefficient (r s ) and Kruskal-Wallis tests were performed using SPSS. RESULTS A moderate correlation (r s = -0.51; p < 0.001) was found between the ARAT and 9-HPT scores for the more impaired hand. Likewise, a moderate correlation was found between UEFS and the physical health composite scores (PHCSs) of MSQOL-54 (r s = -0.59; p < 0.001). Finally, performances on ARAT, 9-HPT, and UEFS differed between the employed individuals and those on long-term disability (p = 0.007, p < 0.001, and p = 0.001). CONCLUSION The UEFS moderately correlated with the QOL measure, and considering the UESF is a patient-reported outcome, it could be used to complement routinely captured measures of assessing UE function. Further study is warranted to determine which measure, or combination of measures, is more sensitive to changes in UE function over time.
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Affiliation(s)
- Aman Saini
- Office of the Saskatchewan MS Clinical Research Chair, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
| | - Audrey Zucker-Levin
- School of Rehabilitation Science, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
| | - Benjamin McMillan
- Office of the Saskatchewan MS Clinical Research Chair, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
| | - Pawan Kumar
- College of Kinesiology, University of Saskatchewan, Saskatchewan, Canada
| | - Sarah Donkers
- School of Rehabilitation Science, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
| | - Michael C. Levin
- Office of the Saskatchewan MS Clinical Research Chair, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
- Department of Medicine, Neurology Division, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
- Department of Anatomy, Physiology and Pharmacology, College of Medicine, University of Saskatchewan, Saskatchewan, Canada
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23
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Alonso-Moreno M, Ladrón-Guevara M, Ciudad-Gutiérrez P. Systematic review of gender bias in clinical trials of monoclonal antibodies for the treatment of multiple sclerosis. Neurologia 2021; 38:S0213-4853(21)00008-6. [PMID: 33775476 DOI: 10.1016/j.nrl.2021.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/01/2021] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION This article analyses the presence of gender bias in clinical trials of monoclonal antibodies used to treat multiple sclerosis. MATERIAL AND METHODS We performed a systematic review of controlled clinical trials of 4 monoclonal antibodies used to treat multiple sclerosis (natalizumab, rituximab, alemtuzumab, and ocrelizumab). We searched the PubMed/MEDLINE database for articles published in English before March 2020. The study was conducted in accordance with the relevant international recommendations. RESULTS The search identified 89 articles, 55 of which met the inclusion criteria. Of all patients included in these trials, 64.6% were women. The lead authors of 10 of the studies were women. Fifteen of the 55 studies included a sex-based analysis of the primary endpoint. Only 8 articles discussed the results separately for men and for women. CONCLUSIONS The clinical trials of these 4 monoclonal antibodies present a significant gender bias. In most cases, the primary and secondary endpoints are not analyzed according to patient sex, despite the fact that international recommendations include this as a minimum requirement for ensuring scientific validity and obtaining appropriate results for extrapolation to the wider population.
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Affiliation(s)
- M Alonso-Moreno
- Pharmacy Service, Hospital Universitario Virgen del Rocío, Avenue Manuel Siurot, 41013 Seville, Spain.
| | - M Ladrón-Guevara
- Pharmacy Service, Hospital Universitario Virgen del Rocío, Avenue Manuel Siurot, 41013 Seville, Spain
| | - P Ciudad-Gutiérrez
- Pharmacy Service, Hospital Universitario Virgen del Rocío, Avenue Manuel Siurot, 41013 Seville, Spain
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Ostolaza A, Corroza J, Ayuso T. Multiple sclerosis and aging: comorbidity and treatment challenges. Mult Scler Relat Disord 2021; 50:102815. [PMID: 33581613 DOI: 10.1016/j.msard.2021.102815] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prevalence of elderly patients with MS is increasing, in conjunction with the ageing general population. This review will examine the principal characteristics of elderly patients with MS and how the concomitant pathologies affect them. Finally, it will assess the impact of the medications on these patients and whether it would be safe to discontinue the disease-modifying treatment. METHODS Searches using PubMed were conducted in October 2020 to collect studies assessing the impact of age and comorbidities on patients with MS. RESULTS Several studies showed that aged patients develop concomitant pathologies that could worsen the disease's prognosis. Also, MS itself may be closely related to cognitive impairment, even though the exact etiopathogenic mechanism of it is still unclear. To date, safety and efficacy of currently available drugs remain unassessed in elderly populations. These treatments may not be beneficial in preventing the progression of disability in ageing people with no signs of inflammatory activity, and discontinuation of treatment is often discussed in this subgroup of patients. CONCLUSIONS The presence of cardiovascular pathology, psychiatric disorders, diabetes or cancer is further associated with increased mortality in MS patients. The diagnosis and treatment of the disease is challenged by both age-related comorbidities and clinical variations compared to younger patients. It may be safe to discontinue treatment in elderly patients with no clinico-radiological activity.
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Affiliation(s)
- Aiora Ostolaza
- Department of Neurology, Complejo Hospitalario de Navarra-IdiSNA (Navarra Institute for Health Research), Pamplona, Navarra, 31008, Spain.
| | - Jon Corroza
- Department of Neurology, Complejo Hospitalario de Navarra-IdiSNA (Navarra Institute for Health Research), Pamplona, Navarra, 31008, Spain
| | - Teresa Ayuso
- Department of Neurology, Complejo Hospitalario de Navarra-IdiSNA (Navarra Institute for Health Research), Pamplona, Navarra, 31008, Spain
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Abstract
PURPOSE OF REVIEW Based on the knowledge of disease mechanisms in the progressive course of multiple sclerosis and the experience from randomized clinical trials, we assessed the timing of disease-modifying therapy in patients with progressive multiple sclerosis to define the optimal window of opportunity for treatment of progressive multiple sclerosis. RECENT FINDINGS In progressive multiple sclerosis both small molecules that cross the blood--brain barrier (siponimod) and monoclonal antibodies (ocrelizumab) have shown therapeutic efficacy and have been approved for treatment of progressive multiple sclerosis. However, the majority of phase II and phase III trials in progressive forms of multiple sclerosis have been negative, probably owing to either late start of treatment or use of drugs that are ineffective for treatment of progressive multiple sclerosis. SUMMARY Results from phase II and III trials suggest that the window of opportunity for treatment of progressive multiple sclerosis with anti-inflammatory drugs is predominantly in the early phase of the progressive disease course when patients have lower age, shorter duration of progressive multiple sclerosis, and more pronounced clinical and MRI inflammatory activity. Ongoing trials of neuroprotective drugs may widen the window of opportunity by expanding targeted pathophysiologies.
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26
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Bose G, Freedman MS. Recent advances and remaining questions of autologous hematopoietic stem cell transplantation in multiple sclerosis. J Neurol Sci 2021; 421:117324. [PMID: 33497951 DOI: 10.1016/j.jns.2021.117324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/29/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
The judicious use of autologous hematopoietic stem cell transplantation (AHSCT) for MS requires understanding the potential benefits, identifying the most appropriate patient, and acknowledging the risks and differences between different protocols. Recently, AHSCT for MS is occurring more frequently, with a better safety profile than earlier studies. This review assesses recently published studies to determine the advances that have been made and remaining questions that future studies are poised to answer. We included studies from January 2016 to November 2020 with 20 or more patients. The benefits of AHSCT, including "no evidence of disease activity", functional and patient-reported outcomes, novel biomarkers such as brain atrophy or neurofilament light chain, and cost-effectiveness were assessed. The patient selection, treatment protocols, and safety outcomes differ between reports. The overall efficacy of AHSCT is better than standard treatments. Younger patients with highly active disease have greater chance for improvement, while patients who have comorbidities, failed more treatments, and are transitioning to a more progressive phase may not respond as well to AHSCT. The safety profiles for all AHSCT protocols is improving, however the durability of treatment response may not be the same for all protocols. The goal of AHSCT is to stop disease activity, avoid worsening disability, and obviate the need for further disease-modifying treatment, while improving patient quality of life and minimizing treatment-related risk. Results from currently enrolling randomized controlled trials, as well as ongoing registries, will provide more evidence for the safe and appropriate use of AHSCT.
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Affiliation(s)
- Gauruv Bose
- University of Ottawa, The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada.
| | - Mark S Freedman
- University of Ottawa, The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital General Campus, 501 Smyth Road, Box 606, Ottawa, ON K1H 8L6, Canada.
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27
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Bergman J, Burman J, Bergenheim T, Svenningsson A. Intrathecal treatment trial of rituximab in progressive MS: results after a 2-year extension. J Neurol 2020; 268:651-657. [PMID: 32901316 PMCID: PMC7880973 DOI: 10.1007/s00415-020-10210-0] [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: 06/01/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 10/29/2022]
Abstract
OBJECTIVES To evaluate the effect of intrathecally (IT) delivered rituximab as a therapeutic intervention for progressive multiple sclerosis (PMS) during a 3-year follow-up period. METHODS Participants of a 1-year open-label phase 1b study of IT delivered rituximab to patients with PMS were offered extended treatment with follow-up for an additional 2 years. During the extension phase, treatment with 25 mg rituximab was administered every 6 months via a subcutaneous Ommaya reservoir connected to the right frontal horn with a ventricular catheter. RESULTS Mild to moderate vertigo and nausea occurred in 4 out of 14 participants as temporary adverse events associated with IT rituximab infusion. During the entire 3-year period, two cases of low-virulent bacterial meningitis occurred, which were successfully treated. Walking speed deteriorated significantly during the study. CONCLUSIONS IT administration of rituximab via a ventricular catheter was well tolerated. Considering the meningitis cases, the risk of infection was not negligible. The continued loss of walking speed indicates that IT rituximab was not able to stop disease progression. CLASSIFICATION OF EVIDENCE This study provides class IV evidence that intraventricularly administered rituximab in progressive MS is associated with a risk for bacterial meningitis and does not halt disease progression. EU CLINICAL TRIAL REGISTER EudraCT; 2008-002626-11 and 2012-000721-53.
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Affiliation(s)
- Joakim Bergman
- Department of Clinical Science, Umeå University, Umeå, Sweden
| | - Joachim Burman
- Department of Neurosciences, Uppsala University, Uppsala, Sweden
| | | | - Anders Svenningsson
- Department of Clinical Science, Umeå University, Umeå, Sweden. .,Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Danderyd Hospital, 182 88, Stockholm, Sweden.
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Real-World Results of Ocrelizumab Treatment for Primary Progressive Multiple Sclerosis. Mult Scler Int 2020; 2020:5463451. [PMID: 32607256 PMCID: PMC7313157 DOI: 10.1155/2020/5463451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/08/2020] [Accepted: 05/23/2020] [Indexed: 12/31/2022] Open
Abstract
Background Recently, ocrelizumab (Ocrevus®) was approved for the treatment of primary progressive multiple sclerosis (PPMS) based on data from the ORATORIO clinical trial. Real-world data about the clinical effectiveness of ocrelizumab has yet to be gathered. Objective The aim of this study was to provide data about the clinical effectiveness of ocrelizumab for patients diagnosed with PPMS in a real-world setting. Methods We conducted a retrospective cohort study of all patients with PPMS who started ocrelizumab treatment (n = 21) in St. Antonius Hospital (Utrecht/Nieuwegein, the Netherlands) between April 2018 and December 31, 2018. Primary outcome was pre- versus post-ocrelizumab disability worsening rate (from 96 weeks prior to first ocrelizumab administration up to 24 weeks post first ocrelizumab administration). Results Disability worsening rate while on treatment significantly differed (lower) from disability worsening rate in pre-treatment period (Z = −2.81, p ≤ .01). Three out of 17 patients showed a clinically relevant improvement in disability status after treatment start. Conclusion Ocrelizumab can stabilize disability progression in patients with PPMS. Some patients even showed a clinically relevant improvement in disability status. Further research should help to identify which patients benefit most from ocrelizumab.
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Abstract
Ocrelizumab ist ein monoklonaler Antikörper, der sich gegen das Differenzierungsantigen CD20 richtet und zu einer effektiven längerfristigen Depletion von Lymphozyten, insbesondere von B‑Zellen, führt. Unlängst publizierte Phase-3-Studien belegen, dass Ocrelizumab sowohl bei der Behandlung der schubförmigen als auch der primär progressiven Multiplen Sklerose (MS) wirksam ist. Darauf basierend wurde Ocrelizumab als erstes Medikament zur Behandlung der primär chronisch-progredienten MS zugelassen. Um diesen Durchbruch besser in den Kontext des heutigen MS-Therapiekanons einordnen zu können, lohnt sowohl ein Blick zurück auf die Entwicklung der antikörpervermittelten CD20-Depletion als auch auf die der Zulassung zugrunde liegenden Studien sowie deren Extensionsphasen. Diese Übersichtsarbeit diskutiert die verfügbaren Daten zur Wirksamkeit und Sicherheit der langfristigen B‑Zell-Depletion bei MS-Patienten und erörtert den aktuellen Kenntnisstand zur Rolle von B‑Lymphozyten in der Immunpathogenese der MS.
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Allen-Philbey K, Middleton R, Tuite-Dalton K, Baker E, Stennett A, Albor C, Schmierer K. Can We Improve the Monitoring of People With Multiple Sclerosis Using Simple Tools, Data Sharing, and Patient Engagement? Front Neurol 2020; 11:464. [PMID: 32655472 PMCID: PMC7325931 DOI: 10.3389/fneur.2020.00464] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 04/29/2020] [Indexed: 12/14/2022] Open
Abstract
Technological innovation is transforming traditional clinical practice, enabling people with multiple sclerosis (pwMS) to contribute health care outcome data remotely between clinic visits. In both relapsing and progressive forms of multiple sclerosis (MS), patients may experience variable disability accrual and symptoms throughout their disease course. The potential impact on the quality of life (QoL) in pwMS and their families and carers is profound. The introduction of treatment targets, such as NEDA (no evidence of disease activity) and NEPAD (no evidence of progression or active disease), that guide clinical decision-making, highlight the importance of utilizing sensitive instruments to measure and track disease activity and progression. However, the gold standard neurological disability tool—expanded disability severity scale (EDSS)—has universally recognized limitations. With strides made in our understanding of MS pathophysiology and DMT responsiveness, maintaining the status quo of measuring disability progression is no longer the recommended option. Outside the clinical trial setting, a comprehensive monitoring system has not been robustly established for pwMS. A 21st-century approach is required to integrate clinical, paraclinical, and patient-reported outcome (PRO) data from electronic health records, local databases, and patient registries. Patient and public involvement (PPI) is critical in the design and implementation of this workflow. To take full advantage of the potential of digital technology in the monitoring and care and QoL of pwMS will require iterative feedback between pwMS, health care professionals (HCPs), scientists, and digital experts.
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Affiliation(s)
- Kimberley Allen-Philbey
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Rod Middleton
- UK MS Register, Swansea University Medical School, Swansea, United Kingdom
| | - Katie Tuite-Dalton
- UK MS Register, Swansea University Medical School, Swansea, United Kingdom
| | - Elaine Baker
- UK MS Register, Swansea University Medical School, Swansea, United Kingdom
| | - Andrea Stennett
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Christo Albor
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Klaus Schmierer
- Clinical Board Medicine (Neuroscience), The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.,The Blizard Institute (Neuroscience, Surgery & Trauma), Queen Mary University of London, London, United Kingdom
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32
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Metaxakis A, Petratou D, Tavernarakis N. Molecular Interventions towards Multiple Sclerosis Treatment. Brain Sci 2020; 10:brainsci10050299. [PMID: 32429225 PMCID: PMC7287961 DOI: 10.3390/brainsci10050299] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 12/24/2022] Open
Abstract
Multiple sclerosis (MS) is an autoimmune life-threatening disease, afflicting millions of people worldwide. Although the disease is non-curable, considerable therapeutic advances have been achieved through molecular immunotherapeutic approaches, such as peptides vaccination, administration of monoclonal antibodies, and immunogenic copolymers. The main aims of these therapeutic strategies are to shift the MS-related autoimmune response towards a non-inflammatory T helper 2 (Th2) cells response, inactivate or ameliorate cytotoxic autoreactive T cells, induce secretion of anti-inflammatory cytokines, and inhibit recruitment of autoreactive lymphocytes to the central nervous system (CNS). These approaches can efficiently treat autoimmune encephalomyelitis (EAE), an essential system to study MS in animals, but they can only partially inhibit disease progress in humans. Nevertheless, modern immunotherapeutic techniques remain the most promising tools for the development of safe MS treatments, specifically targeting the cellular factors that trigger the initiation of the disease.
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Affiliation(s)
- Athanasios Metaxakis
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology Hellas, Nikolaou Plastira 100, 70013 Heraklion, Greece; (A.M.); (D.P.)
| | - Dionysia Petratou
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology Hellas, Nikolaou Plastira 100, 70013 Heraklion, Greece; (A.M.); (D.P.)
| | - Nektarios Tavernarakis
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology Hellas, Nikolaou Plastira 100, 70013 Heraklion, Greece; (A.M.); (D.P.)
- Department of Basic Sciences, Faculty of Medicine, University of Crete, 71110 Heraklion, Greece
- Correspondence: ; Tel.: +30-2810-391066
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33
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Treatment Optimization in Multiple Sclerosis: Canadian MS Working Group Recommendations. Can J Neurol Sci 2020; 47:437-455. [DOI: 10.1017/cjn.2020.66] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract:The Canadian Multiple Sclerosis Working Group has updated its treatment optimization recommendations (TORs) on the optimal use of disease-modifying therapies for patients with all forms of multiple sclerosis (MS). Recommendations provide guidance on initiating effective treatment early in the course of disease, monitoring response to therapy, and modifying or switching therapies to optimize disease control. The current TORs also address the treatment of pediatric MS, progressive MS and the identification and treatment of aggressive forms of the disease. Newer therapies offer improved efficacy, but also have potential safety concerns that must be adequately balanced, notably when treatment sequencing is considered. There are added discussions regarding the management of pregnancy, the future potential of biomarkers and consideration as to when it may be prudent to stop therapy. These TORs are meant to be used and interpreted by all neurologists with a special interest in the management of MS.
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34
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Vaughn CB, Jakimovski D, Kavak KS, Ramanathan M, Benedict RHB, Zivadinov R, Weinstock-Guttman B. Epidemiology and treatment of multiple sclerosis in elderly populations. Nat Rev Neurol 2020; 15:329-342. [PMID: 31000816 DOI: 10.1038/s41582-019-0183-3] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The prevalence of multiple sclerosis (MS) and the age of affected patients are increasing owing to increased longevity of the general population and the availability of effective disease-modifying therapies. However, ageing presents unique challenges in patients with MS largely as a result of their increased frequency of age-related and MS-related comorbidities as well as transition of the disease course from an inflammatory to a neurodegenerative phenotype. Immunosenescence (the weakening of the immune system associated with natural ageing) might be at least partly responsible for this transition, which further complicates disease management. Currently approved therapies for MS are effective in preventing relapse but are not as effective in preventing the accumulation of disability associated with ageing and disease progression. Thus, ageing patients with MS represent a uniquely challenging population that is currently underserved by existing therapeutic regimens. This Review focuses on the epidemiology of MS in ageing patients. Unique considerations relevant to this population are discussed, including the immunology and pathobiology of the complex relationship between ageing and MS, the safety and efficacy of disease-modifying therapies, when discontinuation of treatment might be appropriate and the important role of approaches to support wellness and cognition.
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Affiliation(s)
- Caila B Vaughn
- Jacobs Multiple Sclerosis Center for Treatment and Research, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York (SUNY), Buffalo, NY, USA
| | - Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York (SUNY), Buffalo, NY, USA
| | - Katelyn S Kavak
- Jacobs Multiple Sclerosis Center for Treatment and Research, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York (SUNY), Buffalo, NY, USA
| | - Murali Ramanathan
- Department of Pharmaceutical Sciences, Jacobs School of Medicine and Biomedical Sciences, State University of New York (SUNY), Buffalo, NY, USA
| | - Ralph H B Benedict
- Jacobs Multiple Sclerosis Center for Treatment and Research, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York (SUNY), Buffalo, NY, USA
| | - Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York (SUNY), Buffalo, NY, USA.,Center for Biomedical Imaging at the Clinical Translational Science Institute, State University of New York (SUNY), Buffalo, NY, USA
| | - Bianca Weinstock-Guttman
- Jacobs Multiple Sclerosis Center for Treatment and Research, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York (SUNY), Buffalo, NY, USA.
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Newsome SD, von Geldern G, Shou H, Baynes M, Marasigan RER, Calabresi PA, Zackowski KM. Longitudinal assessment of hand function in individuals with multiple sclerosis. Mult Scler Relat Disord 2019; 32:107-113. [PMID: 31085489 DOI: 10.1016/j.msard.2019.04.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Little is known about the frequency and severity of hand dysfunction in individuals with multiple sclerosis (MS). Hence, we sought to determine the extent that quantitative tests of hand function detect changes over time, evaluate their relationship to global disability measures, and identify predictors of hand function. METHODS One-hundred and forty-seven individuals with MS were included (96 women, 84 relapsing-remitting MS [RRMS]) along with 35 age-and-sex matched controls. Quantitative tests of hand function (grip strength, pinch strength, 9 hole peg test [9HPT], finger tapping) and leg strength were acquired and normalized to age and sex. Expanded Disability Status Scale (EDSS) and timed 25 foot walk were also obtained. Spearman correlations, multivariate regression models and mixed effects linear regression were used for analysis. RESULTS Our cohort had an EDSS of 3.6 ± 2.2 (median ± SD) and age 44.6 ± 11.9 years. Follow up time was up to 5 years. At baseline, 14/63 individuals with progressive MS (PMS) required more than twice as much time to complete the 9HPT using their dominant hand, compared to controls. Similarly, 11 individuals with PMS had less than 50% of grip strength and 6 had less than 50% of pinch strength, compared to controls. Additionally, 7 individuals with PMS were found to be at least 50% slower than controls in finger tapping. Over two years, 27/85 individuals with MS had more than 20% worsening in their 9HPT results from baseline (17 RRMS, 10 PMS) and 37/74 (20 RRMS, 17 PMS) had more than 20% worsening in their grip strength compared to baseline. CONCLUSIONS Hand function is commonly impaired in individuals with MS. Assessing hand dysfunction with dynamometry and the 9HPT could help improve the precision of detecting changes in hand function over time in MS, and may be more sensitive in detecting changes in PMS. These quantitative tests may be useful as outcome measures in clinical trials using neuroprotective or reparative therapies and rehabilitative interventions.
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Affiliation(s)
- Scott D Newsome
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.
| | | | - Haochang Shou
- Department of Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Moira Baynes
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | | | - Peter A Calabresi
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Kathleen M Zackowski
- National MS Society, New York, NY, USA; Kennedy Krieger Institute, Baltimore MD, USA; Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA
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Abstract
Cladribine is a deoxyadenosine analogue prodrug that preferentially depletes lymphocytes, key cells underlying multiple sclerosis (MS) pathogenesis. Cladribine tablets (Mavenclad®) represent the first short-course oral disease-modifying drug (DMD) for use in MS. The tablets, administered in two short courses 1 year apart, are indicated for the treatment of adults with highly active relapsing MS on the basis of data from pivotal clinical trials, including the phase 3 study CLARITY and its extension. A cumulative cladribine tablets dose of 3.5 mg/kg administered in this fashion in CLARITY reduced clinical relapse, disability progression and MRI-assessed disease activity and also improved some aspects of health-related quality of life (HR-QOL) versus placebo over 96 weeks in adults with relapsing-remitting MS (RRMS). Moreover, in the 96-week extension (plus 24 weeks' supplemental follow-up), no additional clinical benefit was gained from continuing versus discontinuing cladribine tablets after the first two annual courses of therapy, although MRI activity was more notable in a subset of cladribine tablet recipients who discontinued the drug. In post hoc analyses of CLARITY and/or a phase 2b trial, benefits of cladribine tablets were seen in patients with high disease activity (HDA) relapsing MS that were sometimes greater than in patients without HDA. Cladribine tablets have an acceptable tolerability profile and do not appear to be associated with an increased risk of overall infection or with an increased risk of malignancy (vs. matched reference populations). Active comparisons and longer-term follow-up would be beneficial, although current data indicate that for adults with highly active relapsing MS, cladribine tablets are an effective treatment option with the convenience of low-burden, short-course, oral administration.
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Affiliation(s)
- Emma D. Deeks
- 0000 0004 0372 1209grid.420067.7Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754 New Zealand
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