Modafinil for fatigue in MS: A randomized placebo-controlled double-blind study

Efficacy of pharmacologic treatments for fatigue in multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Fatigue is commonly experienced amongst persons with multiple sclerosis (PwMS), decreasing quality of life and increasing the economic burden of care. Several pharmacologic treatments have been studied in randomized clinical trials (RCTs) for fatigue in MS, with conflicting results.

METHODS

We performed a systematic search for RCTs through PubMed and CENTRAL to determine the efficacy and tolerability of amantadine, modafinil, methylphenidate, and 4-aminopyridine as treatments for fatigue in adults with MS in comparison to placebo or other interventions. Outcomes were fatigue severity as measured by Fatigue Severity Scale (FSS), Modified Fatigue Impact Scale (MFIS), or Visual Analog Scale, and frequency of discontinuation due to side effects. Forest plots were generated (random effects model), standardized mean differences (SMD) were used for continuous outcomes, and risk ratio was calculated for the dichotomous outcome. The risk of bias was assessed with the Cochrane risk-of-bias tool, and GRADEpro GDT was used to summarize the evidence.

RESULTS

Of 259 screened studies, 16 met the inclusion criteria for this review. SMD showed a change of -0.26 (95 % CI, -0.54, 0.01) in the direction of medications, representing a decrease of 0.29 in FSS or 3.90 in MFIS (minimally important difference is 0.45 for FSS and 4 for MFIS). The pooled risk ratio for discontinuation was 2.11 (95 % CI, 1.19, 3.77), favoring controls. Most studies were without substantial risk of bias, but the certainty of evidence was low.

CONCLUSION

The studied medications have minimal to no efficacy and an uncertain clinical significance in reducing fatigue in PwMS.

Mindfulness-based stress reduction as perceived by individuals with pathological mental fatigue after an acquired brain injury

After acquired brain injury (ABI), some individuals suffer from long-term fatigue and emotional distress, which affects their work ability and daily life. Mindfulness-based stress reduction (MBSR) has shown promising results in quantitative studies as a complementary treatment for pathological mental fatigue (PMF) after ABI. This study aims to explore how people suffering from lasting PMF after ABI experience MBSR in relation to their PMF, with the intention of better meeting the rehabilitation needs of those affected. Seven individuals (mean age 42 years) who had suffered from long-lasting PMF after ABI took part in the study. None of them had resumed work due to their PMF, but all had recovered from neurological impairments. They were interviewed after completing an MBSR course. Thematic analysis of the participants' perspectives suggested that the MBSR program provided them with coping techniques for living with PMF. They gained a deeper understanding of their condition becoming more self-compassionate, and the treatment provided them with a forum for meeting and sharing experiences with others with similar problems. The qualitative results strengthen the evidence for MBSR as a feasible psychoeducative complementary treatment for PMF after ABI.

Assessment of acupuncture's effectiveness in mitigating fatigue among patients afflicted with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Fatigue is a pervasive and debilitating symptom of multiple sclerosis (MS) that severely impairs quality of life and daily functioning. This emphasizes the essential need for complementary therapies that go beyond conventional therapies. Although acupuncture is gaining popularity in MS management, there is a critical lack of rigorous research on its effectiveness in alleviating symptoms.

METHODS

A comprehensive literature search was conducted across multiple databases, focusing on studies evaluating acupuncture's effectiveness in alleviating fatigue in MS patients. Key outcomes measured in the analysis included fatigue, quality of life, and disability.

RESULTS

Six studies were included in the analysis, consisting of two observational studies and four randomized controlled trials. The analysis focused on evaluating acupuncture's efficacy in alleviating fatigue induced by MS. Despite variations in acupuncture protocols, outcome metrics, and control conditions, our meta-analysis revealed that acupuncture significantly reduces fatigue (MD: -0.92, 95 % CI: -1.36 to -0.47, p < 0.0001) and enhances quality of life (SMD: 0.91, 95 % CI: 0.07-1.74, p = 0.03), underscoring its potential as a therapeutic intervention in the management of MS.

CONCLUSION

The meta-analysis suggests a notable improvement in MS-related fatigue following acupuncture, both compared to controls and pre-treatment levels, positioning it as a potential adjunct therapy. However, the prevalent risk of bias in these studies necessitates further high-quality research, along with studies involving larger patient cohorts, to definitively ascertain acupuncture's efficacy and safety in this context.

Comparative effectiveness of cognitive behavioural therapy, modafinil, and their combination for treating fatigue in multiple sclerosis (COMBO-MS): a randomised, statistician-blinded, parallel-arm trial

BACKGROUND

Fatigue is one of the most disabling symptoms reported by people with multiple sclerosis. Although behavioural and pharmacological interventions might be partly beneficial, their combined effects have not been evaluated for multiple sclerosis fatigue, or examined with sufficient consideration of characteristics that might affect treatment response. In this comparative effectiveness research trial, we compared the effectiveness of cognitive behavioural therapy (CBT), modafinil, and their combination for treating multiple sclerosis fatigue.

METHODS

This randomised, analyst-blinded, parallel-arm, comparative effectiveness trial was done at two universities in the USA. Adults (aged ≥18 years) with multiple sclerosis and problematic fatigue (Fatigue Severity Scale [FSS] score ≥4) were randomly assigned (1:1:1), using a web-based treatment assignment system with minimisation, to receive CBT, modafinil, or both for 12 weeks. Statisticians were masked to group assignment, but participants, study neurologists, CBT interventionalists, and coordinators were not masked to treatment assignment. The primary outcome was the change in Modified Fatigue Impact Scale (MFIS) from baseline to 12 weeks, assessed using multiple linear regression, adjusted for age, sex, study site, anxiety, pain, baselines MFIS score, and physical activity. Analyses were done by intent to treat. The trial was registered with clinicaltrials.gov, NCT03621761, and is completed.

FINDINGS

Between Nov 15, 2018, and June 2, 2021, 336 participants were randomly assigned treatment (114 assigned to CBT, 114 assigned to modafinil, and 108 assigned to combination therapy). At 12 weeks, CBT (n=103), modafinil (n=107), and combination therapy (n=102) were associated with clinically meaningful within-group MFIS reductions of 15·20 (SD 11·90), 16·90 (15·90), and 17·30 (16·20) points, respectively. Change in MFIS scores from baseline to 12 weeks did not differ between groups: relative to combination therapy, the adjusted total mean difference in MFIS change score was 1·88 (95% CI -2·21 to 5·96) for CBT and 1·20 (-2·83 to 5·23) for modafinil. Most common adverse events for modafinil-containing treatment groups included insomnia (eight [7%] for modafinil and eight [7%] for combination therapy) and anxiety (three [3%] for modafinil and nine [8%] for combination therapy).

INTERPRETATION

Modafinil, CBT, and combination therapy were associated with similar reductions in the effects of multiple sclerosis fatigue at 12 weeks. Combination therapy was not associated with augmented improvement compared with the individual interventions. Further research is needed to determine whether effects of these interventions on multiple sclerosis-related fatigue is influenced by sleep hygiene and sleepiness. No serious adverse events related to the study drug were encountered.

FUNDING

Patient-Centered Outcomes Research Institute and National Multiple Sclerosis Society.

The use of modafinil for the treatment of fatigue in multiple sclerosis: A systematic review and meta-analysis of controlled clinical trials

INTRODUCTION

Multiple sclerosis (MS) is a debilitating neurological condition affecting nearly one million people across the United States. Among the most prominent symptoms of the condition are excessive fatigue and daytime sleepiness. Numerous clinical trials have investigated the efficacy of modafinil in addressing fatigue among these patients.

OBJECTIVE

The objective of the present study is to assess the safety and efficacy of modafinil for the treatment of fatigue in MS.

METHODOLOGY

An electronic search of PUBMED, ScienceDirect, and Cochrane Central was conducted for articles published from inception to December 2023 using search terms such as "modafinil," "fatigue," and "MS."

RESULTS

Seven studies were included in our analysis. Modafinil leads to a meaningful reduction in fatigue when compared with placebo, as measured by Modified Fatigue Impact Scale [mean difference (MD) = -4.42 [-8.01, -.84]; I2 = 45%; p = .02] and Epworth Sleepiness Scale [MD = -.87 [-1.64, -.10]; I2 = 0%; p = .03]. Modafinil also demonstrated a greater risk of precipitating adverse events (e.g., insomnia, gastrointestinal symptoms) when compared with placebo [RR = 1.30 [1.03, 1.66]; I2 = 0%; p = .03]. In quality-of-life assessments, modafinil was associated with overall improvement in well-being [standardized mean difference = .18 [.01, .35]; I2 = 56%; p = .04].

CONCLUSION

The data indicates that modafinil confers a therapeutic benefit when treating fatigue in patients with MS and improves overall quality of life; however, there is a risk of precipitating adverse events. Ultimately, higher quality of evidence may be required to better inform clinical management.

Fatigue may improve equally after balance and endurance training in multiple sclerosis: a randomised, crossover clinical trial

Introduction

Fatigue and poor balance are frequent and severe problems in multiple sclerosis (MS) that may interact. Endurance training is known to be effective on fatigue. This study aims to test if balance training is more effective against MS fatigue.

Methods

A randomised crossover trial was run, recruiting 31 MS people (21 women; median age: 46 years, range: 30-64; median EDSS: 4, range: 2.5-5). Participants received balance and endurance training alternately (15 one-to-one sessions, 5 days/week) and were assessed before (T0), after (T1), and 30 days after treatment ended (T2). The Modified Fatigue Impact Scale (MFIS) with scores linearised through Rasch analysis was the primary outcome (the lower the measure, the better the condition, i.e., the lower the fatigue symptoms). The Equiscale balance scale and posturography (EquiTest) were used to assess balance. Linear mixed-effects models with ANOVA were used for significance testing.

Results

Thirteen participants had no carryover effect and were included in the primary analysis. Fatigue significantly changed across the three time points (F2,58 = 16.0; p < 0.001), but no difference across treatments was found. Altogether, both treatments significantly improved the MFIS measure at T1 (95%CI: -1.24 logits; mean: -1.67 to -0.81 logits) and T2 (95%CI: -1.04; mean: -1.49 to -0.60) compared to T0 (95%CI: -0.51; mean: -0.95 to -0.08; p ≤ 0.001). Equiscale and posturography highlighted balance improvement after balance training but not after endurance training.

Conclusion

Balance and endurance training could similarly reduce fatigue in MS patients in the short term. However, only balance training also improved balance in MS.

Long-term effectiveness of a cognitive behavioural therapy (CBT) in the management of fatigue in patients with relapsing remitting multiple sclerosis (RRMS): a multicentre, randomised, open-label, controlled trial versus standard care

BACKGROUND

Fatigue is a disabling symptom of multiple sclerosis (MS). The lack of effective therapeutics has promoted the development of cognitive behavioural therapy (CBT)-based fatigue management programmes. However, their efficacy does not sustain over time. We proposed to test the long-term effectiveness of a 6-week fatigue programme supplemented with four booster sessions ('FACETS+') in patients with relapsing remitting MS (RRMS) and fatigue.

METHODS

This multicentre, randomised, controlled, open-label, parallel-group trial versus standard care enrolled patients with RRMS and fatigue. Participants were randomised to either FACETS+ plus standard care or standard care alone. The primary outcome measure was fatigue impact (Modified Fatigue Impact Scale (MFIS) at 12 months) based on intention-to-treat analyses.

RESULTS

From May 2017 to September 2020, 162 patients were screened; 105 were randomly assigned to FACETS+ (n=57) or standard care (n=48) and 88 completed the primary outcome assessment for the MFIS. At month 12, participants showed improved MFIS compared with baseline in the intervention group (mean difference (MD)=14.0 points; (95% CI 6.45 to 21.5)) and the control group (MD=6.1 points; (95% CI -0.30 to 12.5)) with a significant between-group difference in favour of the intervention group (adjusted MD=7.89 points; (95% CI 1.26 to 14.52), standardised effect size=0.52, p=0.021). No trial-related serious adverse events were reported.

CONCLUSIONS

A 6-week CBT-based programme with four booster sessions is superior to standard care alone to treat MS-related fatigue in the long term (12 months follow-up). The results support the use of the FACETS+ programme for the treatment of MS-related fatigue.

TRIAL REGISTRATION NUMBER

NCT03758820.

The Utility of Methylphenidate for Fatigue in Long-Term Neurological Conditions: A Meta-analytical Review

OBJECTIVE

Fatigue is a chronic and debilitating symptom of many long-term neurological conditions (LTNCs). Although methylphenidate provides some promise in alleviating fatigue in other clinical groups, little work has explored its potential utility within LTNCs. The current systematic review and meta-analysis evaluates the utility of methylphenidate for symptoms of fatigue in LTNCs.

METHODS

Five databases (PsycINFO, MEDLINE, Embase, Scopus, and Cochrane Library) were searched for relevant articles from their inception to February 2022. A purpose-developed evaluation tool was used to assess each study's research quality (QuEST:F).

RESULTS

Of the 1698 articles identified, 11 articles were included within this review (n = 370). Meta-analytical findings reported an overall significant benefit of methylphenidate for symptoms of fatigue across a mixed neurological sample ( g = -0.44; 95% confidence interval, -0.77 to -0.11). Subgroup analyses identified a significantly greater benefit ( P < 0.001) of methylphenidate for fatigue in LTNCs with static pathogenic trajectories (eg, traumatic brain injury) (number needed to treat = 2.5) compared with progressive conditions (eg, multiple sclerosis) (number needed to treat = 40.2).

CONCLUSIONS

Methylphenidate may pose an effective intervention for the treatment of fatigue in a number of LTNCs. Nonetheless, given the quality of the current evidence base, there exists a clear need for further robust assessment of the utility of methylphenidate-with a focus on subgroup-specific variability.

Functional connectivity modifications in monoaminergic circuits occur in fatigued MS patients treated with fampridine and amantadine

BACKGROUND

Monoaminergic network dysfunction may have a role in multiple sclerosis (MS) fatigue pathogenesis.

OBJECTIVE

To investigate modifications of fatigue severity and resting state (RS) functional connectivity (FC) in monoaminergic networks of 45 fatigued MS patients after different symptomatic treatments.

METHODS

Patients were randomly, blindly assigned to fampridine (n = 15), amantadine (n = 15) or placebo (n = 15) treatment and underwent clinical and 3T-MRI evaluations at baseline (t0) and week 4 (w4), i.e. after four weeks of treatment. Fifteen healthy controls (HC) were enrolled. Dopamine-, noradrenaline- and serotonin-related RS FC was assessed by PET-guided constrained independent component analysis.

RESULTS

At t0, MS patients showed widespread monoamine-related RS FC abnormalities. At w4, fatigue scores decreased in all groups (p = range < 0.001-0.002). Concomitantly, fampridine and amantadine patients showed increased insular RS FC in dopamine-related and noradrenaline-related networks (p < 0.001, uncorrected). Amantadine patients also showed increased RS FC of anterior cingulate cortex in dopamine-related and noradrenaline-related networks (p < 0.001, uncorrected). Placebo patients showed increased precuneus/middle cingulate RS FC in the noradrenaline-related network (p < 0.001, uncorrected). In fampridine and placebo patients, just tendencies towards correlations between RS FC and fatigue modifications were found.

CONCLUSIONS

In MS patients, specific RS FC modifications in PET-guided monoaminergic networks were observed, concomitantly with fatigue improvements following treatment.

TRIAL REGISTRATION NUMBER

EudraCT 2010-023678-38.

Sleepiness in neurological disorders

Sleepiness is a frequent and underrecognized symptom in neurological disorders, that impacts functional outcomes and quality of life. Multiple and potentially additive factors might contribute to sleepiness in neurological disorders, including sleep quality alterations, circadian rhythm disorders, drugs, and sleep disorders including sleep apnea or central disorders of hypersomnolence. Physician awareness of the possible symptoms of hypersomnolence, and associated causes is of crucial importance to allow proper identification and treatment of underlying causes. This review first provides a brief overview on clinical aspects of excessive daytime sleepiness, and diagnosis tools, then examines its frequency and mechanisms in various neurological disorders, including neurodegenerative disorders, multiple sclerosis, autoimmune encephalitis, epilepsy, and stroke.

Sleep Disorders in Patients with Neurologic Disease

OBJECTIVE

This article provides an overview of the growing body of evidence showing bidirectional relationships between sleep and various neurologic disorders.

LATEST DEVELOPMENTS

Mounting evidence demonstrates that disrupted sleep can negatively impact various neurologic disease processes, including stroke, multiple sclerosis, epilepsy, neuromuscular disorders including amyotrophic lateral sclerosis, and headache syndromes. Abnormal sleep can also be a precursor to Alzheimer disease and neurodegenerative disease states such as Parkinson disease and dementia with Lewy bodies. Interventions to improve sleep and treat obstructive sleep apnea may play a vital role in preventing neurologic disease development and progression.

ESSENTIAL POINTS

Sleep disorders are common among patients with neurologic disorders. To provide comprehensive care to patients with neurologic conditions, neurologists must ask patients about sleep issues that may warrant further diagnostic testing, treatment, and sleep medicine referral when indicated.

Assessing the impacts of L-carnitine and modafinil on fatigue in Iraqi multiple sclerosis patients

Fatigue is a prevalent symptom experienced by individuals diagnosed with multiple sclerosis (MS), which greatly affects their daily activities and causes frustration and depression, thus affecting their lives and society. This can be prevented through the use of medicines such as L-carnitine and modafinil. The study aimed to examine the effect of L-carnitine and modafinil on fatigue and which one is better for MS patients. This was a clinical trial. This clinical trial was conducted in cooperation between Al-Kut University College and an MS consultant at Al-Zahraa Teaching Hospital in addition to the private neurological clinic from October 1, 2022, to March 15, 2023. Forty participants were split into two groups; both of which were almost identical characteristics regarding age, disease duration, and degree of fatigue. Group I (n = 20): relapsing-remitting MS patients with fatigue received modafinil. Group II (n = 20): relapsing-remitting MS patients with fatigue received L-carnitine. Fatigue was evaluated according to the Modified Fatigue Impact Scale (MFIS). The statistical work was done in SPSS (IBM Corp., Chicago, IL, USA, version 24). P values were calculated by the t-test. Significant data have P = 0.05. After 2 months of treatment, the results show a significant decrease in MFIS in both groups with a higher reduction in patients who use L-carnitine. Both modafinil and L-carnitine show a significant influence on fatigue in MS patients, and these effects are more in L-carnitine.

Increased Inflammation and Treatment of Depression: From Resistance to Reuse, Repurposing, and Redesign

Based on mounting clinical and translational evidence demonstrating the impact of exogenously administered inflammatory stimuli on the brain and behavior, increased endogenous inflammation has received attention as one pathophysiologic process contributing to psychiatric illnesses and particularly depression. Increased endogenous inflammation is observed in a significant proportion of depressed patients and has been associated with reduced responsiveness to standard antidepressant therapies. This chapter presents recent evidence that inflammation affects neurotransmitters and neurocircuits to contribute to specific depressive symptoms including anhedonia, motor slowing, and anxiety, which may preferentially improve after anti-cytokine therapies in patients with evidence of increased inflammation. Existing and novel pharmacological strategies that target inflammation or its downstream effects on the brain and behavior will be discussed in the context of a need for intelligent trial design in order to meaningfully translate these concepts and develop more precise therapies for depressed patients with increased inflammation.

Fatigue, sleepiness and depression in multiple sclerosis: defining the overlaps for a better phenotyping

BACKGROUND AND OBJECTIVES

To define the boundaries and the overlaps between fatigue, sleepiness and depression in patients with multiple sclerosis (MS) by using different tools for each dimension, including instrumental sleep analysis.

METHODS

In this cross-sectional, observational study, 71 MS patients (males/females: 20/51; mean age: 48.9 ± 10.5 years) filled in clinical questionnaires and performed polysomnography followed by maintenance of wakefulness test (MWT). Frequency and reciprocal overlap of sleepiness, fatigue and depression in MS were expressed by Eulero-Venn diagrams; standard multiple regression was used to assess the ability of symptoms to predict each other.

RESULTS

There was a high percentage of fatigued (70%), somnolent (45%) and depressed (27%) patients. Fatigue had the strongest overlap and correlated with both depression (beta: 0.52, p < 0.001) and sleepiness (beta: 0.74, p < 0.001). Somnolence and depression were nearly always accompanied by fatigue and were well differentiated from each other by MWT. Four MS subgroups were identified that had: (1) fatigue only; (2) fatigue and sleepiness (3) fatigue and depression; (4) fatigue, sleepiness and depression.

DISCUSSION

The subjective and objective tools are not able to clearly distinguish fatigue from sleepiness and depression, while only a test of vigilance can be helpful in separating somnolence and depression from each other.

Cognitive fatigability assessment test (cFAST): Development of a new instrument to assess cognitive fatigability and pilot study on its association to perceived fatigue in multiple sclerosis

Background

Fatigue is a common symptom of many diseases, including multiple sclerosis. It manifests as a cognitive or physical condition. Fatigue is poorly understood, and effective therapies are missing. Furthermore, there is a lack of methods to measure fatigue objectively. Fatigability, the measurable decline in performance during a task, has been suggested as a complementary method to quantify fatigue.

Objective

To develop a new and objective measurement of cognitive fatigability and investigate its association with perceived fatigue.

Methods

We introduced the cognitive fatigability assessment test (cFAST), a novel smartphone-based test to quantify cognitive fatigability. Forty-two people with multiple sclerosis (23 fatigued and 19 non-fatigued, defined by the Fatigue Scale for Motor and Cognitive Functions) took part in our validation study. Patients completed cFAST twice. We used t-tests, Monte Carlo sampling, and area under the receiver operating characteristic curves to evaluate our approach using two sets of proposed metrics.

Results

When classifying fatigue, our fatigability metric Δresponse time has a mean area under the receiver operating characteristic curve of 0.74 (95% CI 0.64–0.84), making it the best performing metric for this task. Furthermore, Δresponse time shows a statistically significant difference between the fatigued and non-fatigued groups (t = 2.27, P = .03). Particularly, cognitively-fatigued patients decline in performance, while non-fatigued patients do not.

Conclusions

We introduce cFAST, a new instrument to quantify cognitive fatigability. Our pilot study provides evidence that cognitive fatigability assessment test produces a quantifiable drop in cognitive performance in a short period. Furthermore, our results indicate that cFAST may have the potential to serve as a surrogate for subjective cognitive fatigue. cFAST is significantly shorter than the existing fatigability assessments and does not require specialized equipment. Thus, it could enable frequent and remote monitoring, which could substantially aid clinicians in better understanding and treating fatigue.

Spontaneously Generated Online Patient Experience of Modafinil: A Qualitative and NLP Analysis

Objective: To compare the findings from a qualitative and a natural language processing (NLP) based analysis of online patient experience posts on patient experience of the effectiveness and impact of the drug Modafinil.

Methods: Posts (n = 260) from 5 online social media platforms where posts were publicly available formed the dataset/corpus. Three platforms asked posters to give a numerical rating of Modafinil. Thematic analysis: data was coded and themes generated. Data were categorized into PreModafinil, Acquisition, Dosage, and PostModafinil and compared to identify each poster's own view of whether taking Modafinil was linked to an identifiable outcome. We classified this as positive, mixed, negative, or neutral and compared this with numerical ratings. NLP: Corpus text was speech tagged and keywords and key terms extracted. We identified the following entities: drug names, condition names, symptoms, actions, and side-effects. We searched for simple relationships, collocations, and co-occurrences of entities. To identify causal text, we split the corpus into PreModafinil and PostModafinil and used n-gram analysis. To evaluate sentiment, we calculated the polarity of each post between −1 (negative) and +1 (positive). NLP results were mapped to qualitative results.

Results: Posters had used Modafinil for 33 different primary conditions. Eight themes were identified: the reason for taking (condition or symptom), impact of symptoms, acquisition, dosage, side effects, other interventions tried or compared to, effectiveness of Modafinil, and quality of life outcomes. Posters reported perceived effectiveness as follows: 68% positive, 12% mixed, 18% negative. Our classification was consistent with poster ratings. Of the most frequent 100 keywords/keyterms identified by term extraction 88/100 keywords and 84/100 keyterms mapped directly to the eight themes. Seven keyterms indicated negation and temporal states. Sentiment was as follows 72% positive sentiment 4% neutral 24% negative. Matching of sentiment between the qualitative and NLP methods was accurate in 64.2% of posts. If we allow for one category difference matching was accurate in 85% of posts.

Conclusions: User generated patient experience is a rich resource for evaluating real world effectiveness, understanding patient perspectives, and identifying research gaps. Both methods successfully identified the entities and topics contained in the posts. In contrast to current evidence, posters with a wide range of other conditions found Modafinil effective. Perceived causality and effectiveness were identified by both methods demonstrating the potential to augment existing knowledge.

Treatment of multiple sclerosis fatigue with the synthetic psychoactive drug modafinil

Multiple sclerosis (MS) is a complex disorder characterized by a broad spectrum of symptoms that evolve throughout the disease. Symptoms can be categorized as visible and invisible based on external sight recognition. However, although others poorly recognize it, invisible symptoms such as mood dysfunction, neuropathic pain, or fatigue can significantly affect activities of daily living and the quality of life of people with MS (PwMS). PwMS frequently complain of fatigue, which has physical or cognitive manifestations. Fatigue in MS does not improve or resolve with rest, and it is disproportionate with respect to the exerted effort. Fatigue management in MS is challenging, and a few pharmacological approaches have been successfully proposed. Among them, the drug modafinil has attracted attention because of its properties as a synthetic psychoactive drug. In this review, we focus on the evidence available to date, supporting the use of modafinil in MS fatigue. However, despite the availability of some trials evaluating the effects of modafinil on fatigue, their contrasting results failed to support its usefulness in fatigue management in MS.

Methylphenidate may improve mental fatigue in individuals with multiple sclerosis: A pilot clinical trial

BACKGROUND

Fatigue is the most common symptom in multiple sclerosis (MS), previously attributed to dopamine imbalance. Evidence suggests that methylphenidate, a psychostimulant that increases striatal and prefrontal dopamine levels, is effective in reducing fatigue in various disorders. However, its effect on state vs. trait mental fatigue in MS is yet to be examined.

METHODS

This pilot study investigates the efficacy of methylphenidate on decreasing self-reported mental fatigue in 12 individuals with MS in a double-blind, placebo-controlled, cross-over randomized clinical trial.

RESULTS

Our results show that "state", but not "trait" MS-related fatigue, was reduced after 4 weeks of methylphenidate administration as compared to placebo.

Cortico-subcortical functional connectivity modifications in fatigued multiple sclerosis patients treated with fampridine and amantadine

BACKGROUND AND PURPOSE

Fatigue in multiple sclerosis (MS) is common and disabling; medication efficacy is still not fully proven. The aim of this study was to investigate 4-week modifications of fatigue severity in 45 relapsing-remitting MS patients after different symptomatic treatments, and changes in concomitant resting state (RS) functional connectivity (FC).

METHODS

Patients were randomly, blindly assigned to treatment with fampridine (n = 15), amantadine (n = 15) or placebo (n = 15), and underwent clinical assessment and 3-Tesla RS functional magnetic resonance imaging at baseline (t0) and after 4 weeks (w4) of treatment. Fifteen healthy controls (HCs) were also studied. Changes in modified fatigue impact scale (MFIS) score and network RS FC were assessed.

RESULTS

In MS, abnormalities of network RS FC at t0 did not differ between treatment groups and correlated with fatigue severity. At w4, global scores and subscores on the MFIS decreased in all groups, with no time-by-treatment interaction. At w4, all patient groups had changes in RS FC in several networks, with significant time-by-treatment interactions in basal ganglia, sensorimotor and default-mode networks in fampridine-treated patients versus the other groups, and in frontoparietal network in amantadine-treated patients. In the fampridine group, RS FC changes correlated with concurrently decreased MFIS score (r range = -0.75 to 0.74, p range = 0.003-0.05).

CONCLUSIONS

Fatigue improved in all MS groups, independently of treatment. Concomitant RS FC modifications were located in sensorimotor, inferior frontal and subcortical regions for fampridine- and amantadine-treated patients, and in associative sensory cortices for placebo-treated patients.

Recovery from refractory chronic fatigue syndrome with CBT and modafinil

Many patients with chronic fatigue syndrome (CFS) fail to derive benefit from evidence-based treatments such as cognitive-behavioural therapy (CBT) and graded exercise therapy leading to permanent disability. To discover whether a repeat prescription of modafinil might potentiate the benefits of CBT leading to social recovery as defined by 2 or more point improvement in energy and muscular pain/concentration and return to work or full-time training. Three patients with treatment-resistant CFS (mean duration 17.66 years) treated with modafinil and CBT in a Liaison Psychiatry clinic were retrospectively reviewed. Progress was reviewed at baseline, 4-6 months and 10-24 months. Patients rated their fatigue, pain and concentration using 10-point Likert scales. 2/3 achieved clinically meaningful improvements in energy and pain/concentration and 3/3 achieved social recovery. Modafinil, when prescribed over the medium term, would appear to be a potentially useful potentiating agent when added to CBT.

Safety and efficacy of amantadine, modafinil, and methylphenidate for fatigue in multiple sclerosis: a randomised, placebo-controlled, crossover, double-blind trial

BACKGROUND

Methylphenidate, modafinil, and amantadine are commonly prescribed medications for alleviating fatigue in multiple sclerosis; however, the evidence supporting their efficacy is sparse and conflicting. Our goal was to compare the efficacy of these three medications with each other and placebo in patients with multiple sclerosis fatigue.

METHODS

In this randomised, placebo-controlled, four-sequence, four-period, crossover, double-blind trial, patients with multiple sclerosis who reported fatigue and had a Modified Fatigue Impact Scale (MFIS) score of more than 33 were recruited at two academic multiple sclerosis centres in the USA. Participants received oral amantadine (up to 100 mg twice daily), modafinil (up to 100 mg twice daily), methylphenidate (up to 10 mg twice daily), or placebo, each given for up to 6 weeks. All patients were intended to receive all four study medications, in turn, in one of four different sequences with 2-week washout periods between medications. A biostatistician prepared a concealed allocation schedule, stratified by site, randomly assigning a sequence of medications in approximately a 1:1:1:1 ratio, in blocks of eight, to a consecutive series of numbers. The statistician and pharmacists had no role in assessing the participants or collecting data, and the participants, caregivers, and assessors were masked to allocation. The primary outcome measure was the MFIS measured while taking the highest tolerated dose at week 5 of each medication period, analysed by use of a linear mixed-effect regression model. This trial is registered with ClinicalTrials.gov, NCT03185065 and is closed.

FINDINGS

Between Oct 4, 2017, and Feb 27, 2019, of 169 patients screened, 141 patients were enrolled and randomly assigned to one of four medication administration sequences: 35 (25%) patients to the amantadine, placebo, modafinil, and methylphenidate sequence; 34 (24%) patients to the placebo, methylphenidate, amantadine, and modafinil sequence; 35 (25%) patients to the modafinil, amantadine, methylphenidate, and placebo sequence; and 37 (26%) patients to the methylphenidate, modafinil, placebo, and amantadine sequence. Data from 136 participants were available for the intention-to-treat analysis of the primary outcome. The estimated mean values of MFIS total scores at baseline and the maximal tolerated dose were as follows: 51·3 (95% CI 49·0-53·6) at baseline, 40·6 (38·2-43·1) with placebo, 41·3 (38·8-43·7) with amantadine, 39·0 (36·6-41·4) with modafinil, and 38·6 (36·2-41·0) with methylphenidate (p=0·20 for the overall medication effect in the linear mixed-effect regression model). As compared with placebo (38 [31%] of 124 patients), higher proportions of participants reported adverse events while taking amantadine (49 [39%] of 127 patients), modafinil (50 [40%] of 125 patients), and methylphenidate (51 [40%] of 129 patients). Three serious adverse events occurred during the study (pulmonary embolism and myocarditis while taking amantadine, and a multiple sclerosis exacerbation requiring hospital admission while taking modafinil).

INTERPRETATION

Amantadine, modafinil, and methylphenidate were not superior to placebo in improving multiple sclerosis fatigue and caused more frequent adverse events. The results of this study do not support an indiscriminate use of amantadine, modafinil, or methylphenidate for the treatment of fatigue in multiple sclerosis.

FUNDING

Patient-Centered Outcomes Research Institute.

New Strategies for Rehabilitation and Pharmacological Treatment of Fatigue Syndrome in Multiple Sclerosis

Multiple sclerosis (MS) is the most common autoimmune disease of the central nervous system (CNS), with an inflammatory demyelinating basis and a progressive course. The course of the disease is very diverse and unpredictable. Patients face many problems on a daily basis, such as problems with vision; sensory, balance, and gait disturbances; pain; muscle weakness; spasticity; tremor; urinary and fecal disorders; depression; and rapidly growing fatigue, which significantly influences quality of life among MS patients. Excessive fatigue occurs in most MS patients in all stages of this disease and is named MS-related fatigue. The crucial issue is the lack of effective treatment; therefore, this review focuses not only on the most common treatment methods, but also on additional novel therapies such as whole-body cryotherapy (WBC), functional electrical stimulation (FES), and non-invasive brain stimulation (NIBS). We also highlight the advantages and disadvantages of the most popular clinical scales used to measure fatigue. The entire understanding of the origins of MS-related fatigue may lead to the development of more effective strategies that can improve quality of life among MS patients. A literature search was performed using MEDLINE, EMBASE, and PEDro databases.

The Effect of Coffee and Caffeine Consumption on Patients with Multiple Sclerosis-Related Fatigue

Background: Coffee and caffeine are considered to have beneficial effects in patients with multiple sclerosis (MS), an autoimmune disease of the central nervous system (CNS) that can lead to disability and chronic fatigue. Methods: In the present study the preference in terms of coffee and caffeine consumption in patients with MS was assessed. In total the opinions of 124 MS patients were explored with a questionnaire, which was developed to investigate the consumption behavior and associated beneficial and harmful effects of coffee and caffeine concerning symptoms of fatigue. Results: Our study showed that 37.1% of the included patients experience severe symptoms of fatigue. In our cohort, fatigue was not related to age, type of diagnosis or duration of the disease. The effects of coffee did not differ between MS patients with and without fatigue. Very few side effects linked to coffee consumption were reported, and we could demonstrate that coffee consumption had no negative impact on quality of sleep. A positive effect on everyday life was observed particularly among patients with a mid-level expanded disability status scale (EDSS). The strongest effects of coffee consumption were observed regarding a better ability to concentrate while fulfilling tasks, an expanded attention span and a better structured daily routine. Conclusions: Since coffee showed no severe side effects and in the absence of an effective fatigue therapy, coffee consumption might be a therapeutic approach for selected patients with MS-related fatigue.

Factors associated with fatigue in CNS inflammatory diseases with AQP4 and MOG antibodies

Objective

Fatigue is a common and disabling symptom amongst people with multiple sclerosis, however it has not been compared across the central nervous system (CNS) inflammatory diseases associated with aquaporin‐4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibodies (Ab). We explored the factors associated with fatigue within and across the two diseases, and compared fatigue levels between them.

Methods

We performed a cross‐sectional study of 90 AQP4‐Ab and 44 MOG‐Ab patients. Fatigue was assessed using the Modified Fatigue Impact Scale (MFIS). Clinical, demographic, and psychometric (anxiety, depression, pain) data were used as independent variables. Multivariable linear regression was used to identify significant independent variables associated with fatigue within and across the two diseases.

Results

Within AQP4‐Ab patients, age (P = 0.002), disease duration (P = 0.004), number of clinical attacks (P = 0.001), disability (P = 0.007), pain interference (P < 0.001), anxiety (P = 0.026), and depression (P < 0.001) were significant independent variables. Interestingly, disease duration had a negative association with fatigue (P = 0.004). Within MOG‐Ab patients, pain interference score (P < 0.001) and anxiety (P = 0.001) were significant independent variables. Although fatigue was worse in AQP4‐Ab patients compared to MOG‐Ab patients (P = 0.008) in all patients as well as in those who ever had transverse myelitis (P = 0.023), this was driven by the differences in age, disability and pain interference rather than antibody subtype itself.

Interpretation

Multiple factors, but not the antibody specificity, appear to contribute to fatigue in antibody positive CNS inflammatory diseases. A multifaceted treatment approach is needed to better manage the physical, cognitive, and psychosocial aspects of fatigue in these patients.

Management of Multiple Sclerosis Symptoms and Comorbidities

PURPOSE OF REVIEW

This article discusses the prevalence, identification, and management of multiple sclerosis (MS)-related symptoms and associated comorbidities, including complications that can present at all stages of the disease course.

RECENT FINDINGS

The impact of comorbidities on the outcome of MS is increasingly recognized. This presents an opportunity to impact the course and outcome of MS by identifying and treating associated comorbidities that may be more amenable to treatment than the underlying inflammatory and neurodegenerative disease. The identification of MS-related symptoms and comorbidities is facilitated by brief screening tools, ideally completed by the patient and automatically entered into the patient record, with therapeutic suggestions for the provider. The development of free, open-source screening tools that can be integrated with electronic health records provides opportunities to identify and treat MS-related symptoms and comorbidities at an early stage.

SUMMARY

Identification and management of MS-related symptoms and comorbidities can lead to improved outcomes, improved quality of life, and reduced disease activity. The use of brief patient-reported screening tools at or before the point of care can facilitate identification of symptoms and comorbidities that may be amenable to intervention.

A randomized pragmatic trial of telephone-delivered cognitive behavioral-therapy, modafinil, and combination therapy of both for fatigue in multiple sclerosis: The design of the "COMBO-MS" trial

BACKGROUND

Fatigue is one of the most common and disabling chronic symptoms in multiple sclerosis (MS). Optimization of available treatments for MS-related fatigue has been stymied by lack of comparative effectiveness research that focuses on real-world treatment delivery methods and potential modification of treatment effect by other chronic MS symptoms or disability level. This report describes the design of a patient centered, comparative effectiveness trial of cognitive behavioral-therapy (CBT), modafinil, and combination therapy of both for fatigue in MS ("COMBO-MS").

METHODS

We describe the methods of this pragmatic comparative effectiveness trial that is guided by a team of patient, family, provider, community, and payer stakeholders. Eligible participants with MS and significant fatigue severity are randomly assigned (1:1:1) to received either CBT, modafinil, or a combination of CBT and modafinil for 12 weeks. The primary outcome is change in fatigue impact as measured by the Modified Fatigue Impact Scale (MFIS) at 12 weeks. Secondary outcome measures include ecological momentary assessment (EMA) measures of fatigue intensity, fatigue interference, and fatigability (measured over 7 days' time at baseline and at 12 weeks), and change in MFIS score at 24 weeks.

PROJECTED OUTCOMES

We hypothesize that combination therapy will more effectively ameliorate fatigue severity than either monotherapy, and that heterogeneity of treatment effects will be found based on depression status, presence of known or suspected sleep disorder, and disease severity. Study findings will assist patients, providers, payers, and policy makers to provide more effective care for managing fatigue in MS.

Role of Inflammation in Depression and Treatment Implications

Approximately one third of depressed patients fail to respond to currently available antidepressant therapies. Therefore, new conceptual frameworks are needed to identify pathophysiologic pathways and neurobiological targets for the development of novel treatment strategies. In this regard, recent evidence suggests that inflammation may contribute to symptoms relevant to a number of psychiatric disorders and particularly depression. Numerous studies (including meta-analyses) have found elevated peripheral and central inflammatory cytokines and acute phase proteins in depression. Chronic exposure to increased inflammation is thought to drive changes in neurotransmitters and neurocircuits that lead to depressive symptoms and that may also interfere with or circumvent the efficacy of antidepressants. Indeed, patients with high inflammation have been shown to exhibit poor response to conventional antidepressant therapies. Recent developments in our ability to understand and measure the effects of inflammation on the brain in patients have opened new doors for the testing of novel treatment strategies that target the immune system or its consequences on neurotransmitter systems. Such recent developments in the field of behavioral immunology and their translational implications for the treatment of depression are discussed herein.

Multiple sclerosis

Multiple sclerosis (MS) is the most common chronic inflammatory, demyelinating and neurodegenerative disease of the central nervous system in young adults. This disorder is a heterogeneous, multifactorial, immune-mediated disease that is influenced by both genetic and environmental factors. In most patients, reversible episodes of neurological dysfunction lasting several days or weeks characterize the initial stages of the disease (that is, clinically isolated syndrome and relapsing-remitting MS). Over time, irreversible clinical and cognitive deficits develop. A minority of patients have a progressive disease course from the onset. The pathological hallmark of MS is the formation of demyelinating lesions in the brain and spinal cord, which can be associated with neuro-axonal damage. Focal lesions are thought to be caused by the infiltration of immune cells, including T cells, B cells and myeloid cells, into the central nervous system parenchyma, with associated injury. MS is associated with a substantial burden on society owing to the high cost of the available treatments and poorer employment prospects and job retention for patients and their caregivers.

Autologous hematopoietic stem cell transplantation improves fatigue in multiple sclerosis

BACKGROUND

Fatigue is a common problem in multiple sclerosis (MS) affecting as many as 90% of patients. The Fatigue Impact Scale (FIS) is a validated measure of fatigue in MS patients. The cause of fatigue in MS is likely multifactorial, with some evidence that ongoing central nervous system (CNS) inflammation is a contributing factor. Immunoablation and autologous hematopoietic stem cell transplantation (aHSCT) have been shown to halt ongoing CNS inflammation.

OBJECTIVE

To investigate whether halting all ongoing inflammation with aHSCT impacts FIS scores in patients with severe MS.

METHODS

In the Canadian aHSCT study ( ClinicalTrials.gov , NCT01099930), 23 patients underwent aHSCT and had FIS prospectively collected every 6 months for 36 months of follow-up. Change in FIS was analysed by repeated-measures analysis of variance (RMANOVA) with multiple linear regression to determine independent predictors.

RESULTS

The median FIS score decreased 36%, from 36 to 23 (p = 0.001), and four patients had 100% reduction. Improvement in FIS correlated with lower age and Expanded Disability Status Scale at baseline, as well as increased independence as evidenced by a return to gainful employment and even driving.

CONCLUSION

Patients had significantly less fatigue on average after aHSCT. This may serve to better understand the contribution of ongoing CNS inflammation to fatigue peculiar to MS.

Imaging the Role of Inflammation in Mood and Anxiety-related Disorders

Background

Studies investigating the impact of a variety of inflammatory stimuli on the brain and behavior have reported evidence that inflammation and release of inflammatory cytokines affect circuitry relevant to both reward and threat sensitivity to contribute to behavioral change. Of relevance to mood and anxiety-related disorders, biomarkers of inflammation such as inflammatory cytokines and acute-phase proteins are reliably elevated in a significant proportion of patients with major depressive disorder (MDD), bipolar disorder, anxiety disorders and post-traumatic stress disorder (PTSD).

Methods

This review summarized clinical and translational work demonstrating the impact of peripheral inflammation on brain regions and neurotransmitter systems relevant to both reward and threat sensitivity, with a focus on neuroimaging studies involving administration of inflammatory stimuli. Recent translation of these findings to further understand the role of inflammation in mood and anxiety-related disorders is also discussed.

Results

Inflammation was consistently found to affect basal ganglia and cortical reward and motor circuits to drive reduced motivation and motor activity, as well as anxiety-related brain regions including amygdala, insula and anterior cingulate cortex, which may result from cytokine effects on monoamines and glutamate. Similar relationships between inflammation and altered neurocircuitry have been observed in MDD patients with increased peripheral inflammatory markers, and such work is on the horizon for anxiety disorders and PTSD.

Conclusion

Neuroimaging effects of inflammation on reward and threat circuitry may be used as biomarkers of inflammation for future development of novel therapeutic strategies to better treat mood and anxiety-related disorders in patients with high inflammation.

Dietary approaches to treat MS-related fatigue: comparing the modified Paleolithic (Wahls Elimination) and low saturated fat (Swank) diets on perceived fatigue in persons with relapsing-remitting multiple sclerosis: study protocol for a randomized controlled trial

BACKGROUND

Fatigue is one of the most disabling symptoms of multiple sclerosis (MS) and contributes to diminishing quality of life. Although currently available interventions have had limited success in relieving MS-related fatigue, clinically significant reductions in perceived fatigue severity have been reported in a multimodal intervention pilot study that included a Paleolithic diet in addition to stress reduction, exercise, and electrical muscle stimulation. An optimal dietary approach to reducing MS-related fatigue has not been identified. To establish the specific effects of diet on MS symptoms, this study focuses on diet only instead of the previously tested multimodal intervention by comparing the effectiveness of two dietary patterns for the treatment of MS-related fatigue. The purpose of this study is to determine the impact of a modified Paleolithic and low saturated fat diet on perceived fatigue (primary outcome), cognitive and motor symptoms, and quality of life in persons with relapsing-remitting multiple sclerosis (RRMS).

METHODS/DESIGN

This 36-week randomized clinical trial consists of three 12-week periods during which assessments of perceived fatigue, quality of life, motor and cognitive function, physical activity and sleep, diet quality, and social support for eating will be collected. The three 12-week periods will consist of the following: 1.

OBSERVATION

Participants continue eating their usual diet. 2.

INTERVENTION

Participants will be randomized to a modified Paleolithic or low saturated fat diet for the intervention period. Participants will receive support from a registered dietitian (RD) through in-person coaching, telephone calls, and emails. 3.

FOLLOW-UP

Participants will continue the study diet for an additional 12 weeks with minimal RD support to assess the ability of the participants to sustain the study diet on their own.

DISCUSSION

Because fatigue is one of the most common and disabling symptoms of MS, effective management and reduction of MS-related fatigue has the potential to increase quality of life in this population. The results of this study will add to the evidence base for providing dietary recommendations to treat MS-related fatigue and other symptoms associated with this disease.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02914964 . Registered on 24 August 2016.

Is the Choosing Wisely® campaign model applicable to the management of multiple sclerosis in France? A GRESEP pilot study

BACKGROUND

Launched in the US in 2012, Choosing Wisely^® is a campaign promoted by the American Board of Internal Medicine (ABIM) Foundation with the goal of improving healthcare effectiveness by avoiding wasteful or unnecessary medical tests, treatments and procedures. It uses concise recommendations produced by national medical societies to start discussions between physicians and patients on the relevance of these services as part of a shared decision-making process. The Multiple Sclerosis Focus Group (Groupe de Reflexion Autour de la Sclérose en Plaques; GRESEP) undertook a pilot study to assess the relevance and feasibility of this approach in the management of multiple sclerosis (MS) in France.

METHODS

Recommendations were developed using the formal consensus method from the guidelines of the French National Health Authority (HAS). A steering committee selected the themes and drafted concise evidence reviews. An independent rating group then assessed these recommendations for clarity, relevance and feasibility.

RESULTS

Seven recommendations were accepted: (1) avoid systematic ordering of multimodal evoked potential studies for diagnosing MS; (2) do not treat MS relapses with low-dose oral corticosteroids; (3) when treating MS relapse with high-dose corticosteroids, the systematic use of the intravenous route is unnecessary if the oral route can be used; (4) systematic hospitalization is not necessary for treating MS relapse with high-dose corticosteroid therapy, particularly if the oral route is used, except for the first treated relapse and the presence of exclusion or non-eligibility criteria; (5) in the absence of clinical signs or symptoms of urinary infection, avoid systematic screening with urine microscopy and culture before the administration of corticosteroid therapy for MS relapse in patients using intermittent self-catheterization; (6) avoid antibiotic treatment of clinically asymptomatic MS patients using intermittent self-catheterization, even if urine microscopy and culture reveal the presence of microorganisms; and (7) avoid introducing symptomatic drug treatment for MS-related fatigue.

CONCLUSION

This pilot study, the first of its kind in France, has demonstrated the relevance and feasibility of adapting the Choosing Wisely^® model to MS by practitioners specializing in the disorder. However, the acceptability of these recommendations by other practitioners in other specialist fields as well as their impact on everyday clinical practices now need to be studied.