1
|
Palavra F, Geria L, Jorge A, Marques M, dos Santos CS, Amaral J, Ribeiro JA, Pereira C, Robalo C. Neutrophil/lymphocyte and monocyte/lymphocyte indexes as potential predictors of relapse at 1 year after diagnosis of pediatric multiple sclerosis: a single-center, exploratory and proof-of-concept study. Front Neurosci 2024; 17:1305176. [PMID: 38287987 PMCID: PMC10822923 DOI: 10.3389/fnins.2023.1305176] [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: 09/30/2023] [Accepted: 12/28/2023] [Indexed: 01/31/2024] Open
Abstract
Introduction Early identification of patients with a more unfavorable outcome in Multiple Sclerosis (MS) is crucial to optimize individualized treatment. Neutrophil-lymphocyte index (NLI) and monocyte-lymphocyte index (MLI) have been considered as potential biomarkers for disease prognosis. Our study aims to investigate the usefulness of NLI and MLI as predictors of relapse, disability progression, and lesion accumulation on magnetic resonance imaging (MRI) 1 year after diagnosis and treatment initiation, in pediatric-onset MS. Methods A retrospective single-center study was conducted, including patients with diagnosis of MS established in pediatric age (<18 years old), at least 1-year of follow-up, and a complete blood count (CBC) performed at diagnosis. We collected the nearest-to-diagnosis NLI and MLI, as well as clinical and imaging variables, at diagnosis and 12 months later. Our cohort was further dichotomized into two groups, based on the presence of relapses. Statistical significance was considered for p < 0.05. Results Eighteen patients (n = 18) were included. The relapsing group had higher mean, minimum, and maximum values for both NLI (5.17 ± 5.85, range: 1.57-11.92) and MLI (0.35 ± 0.22, range: 0.19-0.59), compared to the non-relapsing group (2.19 ± 1.63, range: 1.12-7.32 for NLI, and 0.24 ± 0.09, range: 0.14-0.44 for MLI). A higher percentage of patients in the relapsing group had increased NLI (>1.89, 66.7%) and MLI (>0.21, 66.7%) values than those in the non-relapsing group (46.7%). Patients who presented new T2-hyperintense lesions on MRI after 1 year of follow-up also had higher mean, minimum, and maximum values of both biomarkers. Patients who did not achieve No Evidence of Disease Activity-3 (NEDA-3) state exhibited higher values for both ratios. However, in our sample, no statistically significant correlations were found between MLI and NLI values and the clinical and imaging variables considered. Conclusion The ease of obtaining NLI and MLI from routine blood tests renders them useful biomarkers as a screening tool in longitudinal follow-up. Our study was based on a very small sample size, but it allowed us to verify the feasibility of the protocol used. It is intended to involve other centers in the next phase of this work, testing the possible usefulness of the indices under analysis on a larger sample.
Collapse
Affiliation(s)
- Filipe Palavra
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Laboratory of Pharmacology and Experimental Therapeutics, Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra, Coimbra, Portugal
| | - Leonor Geria
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - André Jorge
- Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Margarida Marques
- Biostatistics and Medical Informatics Laboratory, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Constança Soares dos Santos
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana Amaral
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana Afonso Ribeiro
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristina Pereira
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Conceição Robalo
- Center for Child Development–Neuropediatrics Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| |
Collapse
|
2
|
Costa GD, Comi G. Teriflunomide: an oral therapy for first-line treatment of children and adolescents living with relapsing-remitting multiple sclerosis. Expert Rev Neurother 2023; 23:681-687. [PMID: 37382446 DOI: 10.1080/14737175.2023.2229953] [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: 05/03/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Different disease-modifying therapies (DMTs) have been developed to slow down the progression of pediatric multiple sclerosis (MS). Teriflunomide is one such DMT that has recently been approved for use in pediatric MS in the European Union. AREAS COVERED The article provides an introduction to the mechanism of action of teriflunomide, reviews the clinical trials conducted on the safety and efficacy of the drug, and the optimal dosing and monitoring strategies. EXPERT OPINION Teriflunomide is an oral medication that has shown promise in improving outcomes for pediatric MS patients, including reduced relapse rates and improved quality of life. However, more research is needed to determine its long-term safety in pediatric patients. As MS often presents with an aggressive course in children, the choice of disease-modifying treatment should be carefully evaluated, with a preference for second-line therapy. Despite the potential benefits of teriflunomide, changes in clinical practice may be hindered by factors such as cost and physician familiarity with alternative treatments. Longer-term studies and biomarker identification are areas for improvement, but the future of research in this area holds promise for the continued development and refinement of disease-modifying therapies and more personalized, targeted treatments for pediatric MS patients.
Collapse
Affiliation(s)
| | - Giancarlo Comi
- Faculy of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Multiple Sclerosis center, Casa di Cura Igea, Milan, Italy
| |
Collapse
|
3
|
Vermersch P, Scaramozza M, Levin S, Alroughani R, Deiva K, Pozzilli C, Lyons J, Mokliatchouk O, Pultz J, N’Dure F, Liu S, Badwan R, Branco F, Hood-Humphrey V, Franchimont N, Hanna J, Maghzi AH. Effect of Dimethyl Fumarate vs Interferon β-1a in Patients With Pediatric-Onset Multiple Sclerosis: The CONNECT Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2230439. [PMID: 36169959 PMCID: PMC9520348 DOI: 10.1001/jamanetworkopen.2022.30439] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE With few approved multiple sclerosis therapies in the pediatric population, there is a need for further approved treatment options. Limited data exist for dimethyl fumarate (DMF) treatment in pediatric-onset multiple sclerosis (POMS). OBJECTIVE To compare the efficacy, safety, and tolerability of DMF vs intramuscular interferon β-1a (IFNβ-1a) in POMS. DESIGN, SETTING, AND PARTICIPANTS The CONNECT study was an active-controlled, open-label, rater-blinded 96-week randomized clinical trial in patients with POMS aged 10 to less than 18 years treated between August 2014 and November 2020. Data were analyzed from January through October 2021. INTERVENTIONS Patients were randomized to DMF or IFNβ-1a. MAIN OUTCOMES AND MEASURES The primary end point was the proportion of patients free of new or newly enlarging (N or NE) T2 hyperintense lesions at week 96 among trial completers. Secondary end points included number of N or NE T2 lesions, proportion of patients free of relapse, annualized relapse rate (ARR), and safety. The estimated proportion of participants who were relapse free up to week 96 was calculated based on the Kaplan-Meier method. Adjusted ARR was obtained from a negative binomial regression adjusted for baseline relapse rate, baseline Expanded Disability Status Scale (EDSS) score, and age group. RESULTS Among 150 patients with POMS in the intention-to-treat (ITT) population (median [range] age, 15 [10-17] years; 101 [67.3%] female patients), 78 individuals received DMF and 72 individuals received IFNβ-1a. At week 96, the proportion of patients with no N or NE T2 hyperintense lesions among 103 trial completers was 16.1% (95% CI, 8.0%-27.7%) for DMF vs 4.9% (95% CI, 0.6%-16.5%) for IFNβ-1a, and in a sensitivity analysis among the ITT population, the proportions were 10 patients receiving DMF (12.8%) vs 2 patients receiving IFNβ-1a (2.8%). The estimated proportion of patients who remained relapse free at week 96 was 66.2% for DMF vs 52.3% for IFNβ-1a. Adjusted ARR (95% CI) at week 96 was 0.24 (95% CI, 0.15-0.39) for DMF vs 0.53 (95% CI, 0.33-0.84) for IFNβ-1a; the rate ratio for DMF vs IFNβ-1a was 0.46 (95% CI, 0.26-0.80; P = .006). The number of treatment-emergent adverse events (TEAEs; 74 patients [94.9%] vs 69 patients [95.8%]), serious TEAEs (18 patients [23.1%] vs 21 patients [29.2%]), and treatment discontinuations due to TEAEs (5 patients [6.4%] vs 8 patients [11.1%]) was similar for DMF vs IFNβ-1a. CONCLUSIONS AND RELEVANCE This study found that more pediatric patients with POMS treated with DMF were free of new or newly enlarging T2 lesions and that the adjusted ARR was lower among these patients compared with those treated with interferon β-1a. DMF was well tolerated. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02283853.
Collapse
Affiliation(s)
- Patrick Vermersch
- University Lille, Inserm, Centre Hospitalier Universitaire de Lille, Fédératif Hospitalo-Universitaire Precise, Lille, France
| | | | | | | | - Kumaran Deiva
- Assistance Publique-Hôpitaux de Paris, Pediatric Neurology Department, University Hospitals Paris Saclay, Bicêtre Hospital, Le Kremlin Bicêtre, France
- French Reference Network of Rare Inflammatory Brain and Spinal Diseases, Le Kremlin Bicêtre, France
| | - Carlo Pozzilli
- Sant’ Andrea Multiple Sclerosis Center, Sapienza University, Rome, Italy
| | | | | | - Joe Pultz
- Biogen, Cambridge, Massachusetts
- Now with CR Medicon, Orange, Connecticut
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Bunyan RF, AlAbdulSalam AM, Albarakati RG, Al Harbi AA, Alissa DA, Al-Jedai AH, AlKhawajah NM, Al Malik YM, Almejally MA, Al-Mudaiheem HY, AlNajashi HA, AlShehri AA, Althubaiti IA, AlYafeai RH, Babakkor MA, Cupler EJ, Ka MH, Saeedi JA, Shosha E, Al Jumah MA. Saudi consensus recommendations on the management of multiple sclerosis: MS management in children and adolescents. Mult Scler Relat Disord 2022; 66:104061. [PMID: 35908447 DOI: 10.1016/j.msard.2022.104061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/26/2022] [Accepted: 07/15/2022] [Indexed: 12/01/2022]
Abstract
Multiple sclerosis (MS) most commonly presents in young adults, although 3-5% of patients develop MS prior to the age of 18 years. The new and comprehensive consensus for the management of MS in Saudi Arabia includes recommendations for the management of MS and other CNS inflammatory demyelinating disorders in pediatric and adolescent patients. This article summarizes the key recommendations for the diagnosis and management of these disorders in young patients. Pediatric and adult populations with MS differ in their presentation and clinical course. Careful differential diagnosis is important to exclude alternative diagnoses such as acute disseminated encephalomyelitis (ADEM) or neuromyelitis optica spectrum disorders (NMOSD). The diagnosis of MS in a pediatric/adolescent patient is based on the 2017 McDonald diagnostic criteria, as in adults, once the possibility of ADEM or NMOSD has been ruled out. Few data are available from randomized trials to support the use of a specific disease-modifying therapy (DMT) in this population. Interferons and glatiramer acetate are preferred initial choices for DMTs based on observational evidence, with the requirement of a switch to a more effective DMT if breakthrough MS activity occurs.
Collapse
Affiliation(s)
- Reem F Bunyan
- Department of Neurology, King Fahad Specialist Hospital Dammam, Eastern Region, Saudi Arabia
| | | | - Rayan G Albarakati
- Department of Obstetrics and Gynecology, Majmaah University, Al-Majmaah, Saudi Arabia
| | - Awad A Al Harbi
- Department of Neuroscience, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Dema A Alissa
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | - Ahmed H Al-Jedai
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | - Nuha M AlKhawajah
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Neurology, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Yaser M Al Malik
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Division of Neurology, King Abdulaziz Medical City (National Guard Health Affairs), Riyadh, Saudi Arabia
| | | | | | - Hind A AlNajashi
- Department of Medicine, Division of Neurology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Amani A AlShehri
- Pharmaceutical Care Services, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ibtisam A Althubaiti
- Department of Neurology, King Fahad Military Medical Complex Dhahran, Eastern Region, Saudi Arabia
| | - Rumaiza H AlYafeai
- Department of Psychiatry and Psychology, My Clinic International Medical Co., Jeddah, Saudi Arabia
| | - Mohammed A Babakkor
- Neurology Department, Neuroscience Center, King Abdullah Medical City, Ministry of Health, Makkah Al-Mukarramah, Saudi Arabia
| | - Edward J Cupler
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Mamdouh H Ka
- Department of Neurology, Al Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Jameelah A Saeedi
- Department of Neuroscience, King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Eslam Shosha
- Department of Medicine, Division of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Mohammed A Al Jumah
- Department of Neurology, King Fahad Medical City, Ministry of Health, Riyadh, Saudi Arabia.
| |
Collapse
|
5
|
Menascu S, Fattal-Valevski A, Vaknin-Dembinsky A, Milo R, Geva K, Magalashvili D, Dolev M, Flecther S, Kalron A, Miron S, Hoffmann C, Aloni R, Gurevich M, Achiron A. Effect of natalizumab treatment on the rate of No Evidence of Disease Activity in young adults with multiple sclerosis in relation to pubertal stage. J Neurol Sci 2022; 432:120074. [PMID: 34875473 DOI: 10.1016/j.jns.2021.120074] [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: 06/01/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Abstract
Approximately 40% of young-onset multiple sclerosis (MS) patients experience breakthrough disease, which carries a high risk for long-term disability, and requires using therapies beyond traditional first-line agents. Despite the increasing use of newer disease-modifying treatments (DMTs) in this population, data are not available to guide the need for escalating DMTs and there is a scarcity of data on the effects of natalizumab in children and young adults with active disease. We performed a retrospective analysis of the rate of No Evidence of Disease Activity (NEDA), tolerability, and safety of natalizumab in a multi-center cohort of 36 children and young adults with highly active MS. All patients had active disease and initiated treatment with natalizumab. The primary endpoint was the rate of achieving NEDA-3 status, within two years of natalizumab treatment. To examine a possible effect of age on the outcome of treatment, outcomes were also analyzed by pre-pubertal (n = 13 children aged 9-13 years) and pubertal subgroups (n = 23 young adolescents aged 14-20 years). The NEDA-3 status of the pre-pubertal group was 92% in the first and second year and in the pubertal group - 96% in the first year and 92% in the second year. Natalizumab reduced the number and volume of brain lesions in both pre-pubertal and pubertal groups. Treatment was well-tolerated, only 8 patients (22.2%) had adverse events during the 2-year study period. Our analysis shows that natalizumab is effective and well-tolerated in pre-pubertal and pubertal MS patients.
Collapse
Affiliation(s)
- Shay Menascu
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Aviva Fattal-Valevski
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; Pediatric Neurology Unit, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Ron Milo
- Department of Neurology, Barzilai Medical Center, Ashkelon, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Keren Geva
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; Pediatric Neurology Unit, Meir Medical Center, Kfar-Saba, Israel
| | - David Magalashvili
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Mark Dolev
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shlomo Flecther
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Department of Neurology, Shamir Medical Center (Assaf Harofeh), Be'er Ya'akov, Israel
| | - Alon Kalron
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Shmulik Miron
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Chen Hoffmann
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel; Department of Radiology, Sheba Medical Center, Ramat Gan, Israel
| | - Roy Aloni
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Michael Gurevich
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Anat Achiron
- Multiple Sclerosis Center, Sheba Medical Center, Ramat-Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| |
Collapse
|
6
|
Baló's concentric sclerosis - A rare entity within the spectrum of demyelinating diseases. J Neurol Sci 2021; 428:117570. [PMID: 34261000 DOI: 10.1016/j.jns.2021.117570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/19/2021] [Accepted: 07/05/2021] [Indexed: 11/24/2022]
Abstract
Baló's concentric sclerosis (BCS) is a rare, inflammatory demyelinating disease of the central nervous system (CNS). Historically, BCS was thought to be uniformly fatal and diagnosis was based on postmortem findings. With advances in modern neuroimaging, BCS is currently defined by the presence of concentric layered patterns composed of alternating rings of varying intensity. They are best appreciated on gadolinium-enhanced T1-weighted sequences and predominantly occur in the supratentorial cerebral white matter with sparing of cortical U-fibers. The lamellar pattern of the lesions likely reflects bands of demyelination and relative myelin preservation with minimal axonal loss. While BCS falls within the spectrum of atypical demyelinating diseases, there is ongoing debate over whether BCS is a phenotypical variant of multiple sclerosis (MS) or a separate entity. Corticosteroids comprise first-line therapy but there is ongoing controversy regarding appropriate maintenance therapy. First-line MS disease-modifying therapies such as interferon beta-1a are appropriate for patients who fulfill diagnostic criteria for relapsing-remitting MS. Fingolimod should likely be avoided as Baló-like lesions have been reported during its administration or after withdrawal. Monoclonal antibodies such as natalizumab and rituximab are potentially effective at reducing BCS relapses, but alemtuzumab may be relatively ineffective because humoral immunity does not play a central role in BCS pathogenesis.
Collapse
|
7
|
Alroughani R, Huppke P, Mazurkiewicz-Beldzinska M, Blaschek A, Valis M, Aaen G, Pultz J, Peng X, Beynon V. Delayed-Release Dimethyl Fumarate Safety and Efficacy in Pediatric Patients With Relapsing-Remitting Multiple Sclerosis. Front Neurol 2021; 11:606418. [PMID: 33473248 PMCID: PMC7812971 DOI: 10.3389/fneur.2020.606418] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/26/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Pediatric multiple sclerosis (MS) is rare: only 1.5-5% of MS cases are diagnosed before 18 years of age, and data on disease-modifying therapies (DMTs) for pediatric MS are limited. The CONNECTED study assessed the long-term safety and efficacy of treatment with delayed-release dimethyl fumarate (DMF), an oral MS DMT, in pediatric patients with MS. Methods: CONNECTED is the 96-week extension to FOCUS, a 24-week phase 2 study of patients aged 13-17 years; participants received DMF 240 mg twice daily. Endpoints included (primary) incidence of adverse events (AEs), serious AEs, and DMF discontinuations due to an AE, and (secondary) T2 hyperintense lesion incidence by magnetic resonance imaging and annualized relapse rate (ARR). Results: Twenty participants [median (range) age, 17 (14-18) years; 65% female] who completed FOCUS enrolled into CONNECTED; 17 (85%) completed CONNECTED. Eighteen participants (90%) experienced AEs: the most frequent was flushing (25%). None experienced infections or fever related to low lymphocyte counts. Three participants experienced four serious AEs; none led to DMF discontinuation. Twelve of 17 participants (71%) had no new/newly enlarged T2 lesions from weeks 16-24, two (12%) had one, and one each (6%) had two, three, or five or more lesions [median (range), 0 (0-6)]. Over the full 120-week treatment period, ARR was 0.2, an 84.5% relative reduction (n = 20; 95% confidence interval: 66.8-92.8; p < 0.0001) vs. the year before DMF initiation. Conclusions: The long-term safety and efficacy observed in CONNECTED was consistent with adults, suggesting pediatric and adolescent patients with MS might benefit from DMF treatment.
Collapse
Affiliation(s)
- Raed Alroughani
- Dasman Diabetes Institute, Dasman, Kuwait and Amiri Hospital, Sharq, Kuwait
| | - Peter Huppke
- Department of Pediatrics and Pediatric Neurology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Astrid Blaschek
- Department of Pediatric Neurology and Developmental Medicine, Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Martin Valis
- Neurologicka klinika, Fakultni nemocnice Hradec Kralove, Hradec Kralove, Czechia
| | - Gregory Aaen
- Loma Linda University Children's Health, Loma Linda, CA, United States
| | - Joe Pultz
- Biogen, Cambridge, MA, United States
| | | | | |
Collapse
|
8
|
Savransky A, Rubstein A, Rios MH, Vergel SL, Velasquez MC, Sierra SP, Marcarian G, Alba R, Pugliese AM, Tenembaum S. Prognostic indicators of improvement with therapeutic plasma exchange in pediatric demyelination. Neurology 2019; 93:e2065-e2073. [PMID: 31645471 DOI: 10.1212/wnl.0000000000008551] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/19/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To determine the safety and clinical benefit of therapeutic plasma exchange (TPE) as rescue therapy in children with acute inflammatory demyelinating CNS syndromes and to identify baseline prognostic indicators of treatment improvement. METHODS This single-center retrospective pediatric cohort included all consecutive patients admitted to our hospital over the period from 2003 to 2017 because of a steroid-refractory acute CNS event presumed to be inflammatory who required TPE. Functional status assessment to identify improvement included the following performance category scales: visual outcome, bladder control, gait, and Expanded Disability Status Scale (EDSS). These assessments were performed before and after TPE in every patient. RESULTS Sixty-five children requiring TPE to treat 78 CNS attacks were included for analysis. Median age at TPE was 10.5 years (1.9-18 years); 45% were girls. Seropositivity (aquaporin-4 water channel-immunoglobulin G [IgG] or myelin oligodendrocyte glycoprotein-IgG) was found in 20 of 42 (48%) patients. Attack phenotypes leading to TPE were optic neuritis (ON) in 42%, longitudinally extensive transverse myelitis (LETM) in 31%, ON + LETM in 15%, and other combined syndromes in 11%. Overall, moderate to marked neurologic improvement was observed in 72% of children at the end of TPE and in 88.5% at 6 months of follow-up. Lower baseline scores on the EDSS, visual outcome, and gait scales were found to be independent prognostic indicators of treatment benefit. Sex, age at onset and at TPE, attack phenotype, disease duration, and time from attack onset to TPE initiation were not significantly associated with treatment outcome. Adverse events were observed in 31 of 524 (5.9%) procedures, being severe in 4. CONCLUSIONS TPE was an effective rescue therapy associated with functional improvement. No therapeutic window for TPE initiation was identified in this pediatric cohort. Overall frequency of adverse events was low; however, serious events should be anticipated and avoided. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for children with acute inflammatory demyelinating CNS syndromes, TPE leads to functional improvement.
Collapse
Affiliation(s)
- Andrea Savransky
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Adrian Rubstein
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Marina Huaman Rios
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Silvana L Vergel
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Mabel Castro Velasquez
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Sara Perez Sierra
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Gabriela Marcarian
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Romina Alba
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Ana M Pugliese
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina
| | - Silvia Tenembaum
- From the Department of Neurology (A.S., M.H.R., S.L.V., M.C.V., S.P.S., S.T.) and Transfusion Medicine (G.M., R.A., A.M.P.), National Pediatric Hospital Dr. J.P. Garrahan; and Private Institute of Statistics (A.R.), Buenos Aires, Argentina.
| |
Collapse
|
9
|
Rolfes L, Pfeuffer S, Ruck T, Melzer N, Pawlitzki M, Heming M, Brand M, Wiendl H, Meuth SG. Therapeutic Apheresis in Acute Relapsing Multiple Sclerosis: Current Evidence and Unmet Needs-A Systematic Review. J Clin Med 2019; 8:jcm8101623. [PMID: 31590282 PMCID: PMC6832170 DOI: 10.3390/jcm8101623] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 12/13/2022] Open
Abstract
Multiple sclerosis (MS) is the most abundant inflammatory demyelinating disorder of the central nervous system. Despite recent advances in its long-term immunomodulatory treatment, MS patients still suffer from relapses, significantly contributing to disability accrual. In recent years, apheresis procedures such as therapeutic plasma exchange (TPE) and immunoadsorption (IA) have been recognized as two options for treating MS relapses, that do not respond to standard treatment with corticosteroids. TPE is already incorporated in most international guidelines, although evidence for its use resulted mostly from either case series or small unblinded and/or non-randomized trials. Data on IA are still sparse, but several studies indicate comparable efficacy between both apheresis procedures. This article gives an overview of the published evidence on TPE and IA in the treatment of acute relapses in MS. Further, we outline current evidence regarding individual outcome predictors, describe technical details of apheresis procedures, and discuss apheresis treatment in children and during pregnancy.
Collapse
Affiliation(s)
- Leoni Rolfes
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Steffen Pfeuffer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Tobias Ruck
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Nico Melzer
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Marc Pawlitzki
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Michael Heming
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Marcus Brand
- Department of Internal Medicine D, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| | - Sven G Meuth
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany.
| |
Collapse
|
10
|
Pediatric-onset multiple sclerosis in Brazilian patients: Clinical features, treatment response and comparison to pediatric neuromyelitis optica spectrum disorders. Mult Scler Relat Disord 2018; 25:138-142. [PMID: 30075406 DOI: 10.1016/j.msard.2018.07.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/24/2018] [Accepted: 07/19/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Multiple Sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) are acquired demyelinating syndromes of the central nervous system more frequently in young adults and their beginning before 18 years of age is rare. They are autoimmune diseases with distinct pathophysiology, clinical presentation, treatment and prognoses. During childhood these conditions often present similar clinical features and differential diagnosis among pNMOSD, pMS and acute disseminated encephalomyelitis (ADEM) is still difficult at disease onset. The aim of this article is to describe the epidemiologic and clinical features, to evaluate the response to treatment and to compare the mains characteristics between the patients with MS and NMOSD who had the first event prior to 18 years of age followed at the Universidade Federal de São Paulo (UNIFESP). METHODS Retrospective analysis of patients with MS and NMOSD who started the disease before 18 years of age followed for at UNIFESP. All patients fulfilled the McDonald 2010 criteria for MS and the IPND 2015 criteria or 2006 diagnostic criteria for NMOSD. For treatment analysis, we select patients with a follow-up of more than 6 months. RESULTS Sixty-eight patients fulfilled the inclusion criteria for MS and were selected for analysis. Mean age of onset was 15 years, 73.5% were female and the mean follow-up was 6.7 years. Mean annualized relapse rate (aRR) observed was 0,82 relapse/year and mean progression index (PI) was 0.31 EDSS points/year. The multivariate analysis showed a significant association between the EDSS on first appointment and total number of relapses with neurological disabilities in long term in patients with MS. The treatment with interferon-beta (IFN-β) and glatiramer acetate (GA) was safe and patients treated with high dose IFN-β and GA had a statistically significant reduction in disability progression. Eleven patients fulfilled the inclusion criteria for NMOSD: mean age of onset was 14 years, 72.7% were female and the mean follow-up was 6.3 years. Mean aRR observed was 1.5 relapse/year and mean PI was 2.2 EDSS points/year. The treatment with azathioprine was safe and significant halts disability progression. Patients with NMOSD reached EDSS 6 prior than those with MS. CONCLUSIONS Pediatric demyelinating diseases in Brazil are similar to the diseases described abroad. In patients with pMS, the EDSS score at the first appointment and the total number of relapses were associated with poor prognosis. NMOSD is more severe than MS in pediatric patients. Treatment with DMD and azathioprine was well tolerated and effective in reducing relapse rate and disability.
Collapse
|
11
|
Eyre M, Hacohen Y, Barton C, Hemingway C, Lim M. Therapeutic plasma exchange in paediatric neurology: a critical review and proposed treatment algorithm. Dev Med Child Neurol 2018; 60:765-779. [PMID: 29856068 DOI: 10.1111/dmcn.13925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 12/14/2022]
Abstract
UNLABELLED Therapeutic plasma exchange (TPE) has been a key immunotherapeutic strategy in numerous neurological syndromes, predominantly during the acute phase of illness. This paper reviews the indications, strength of evidence, and safety of TPE in children with neurological conditions. The rarity of these immune conditions in children, alongside an often incomplete understanding of their pathobiology, has limited the development of a robust scientific rationale for TPE therapy and the feasibility of conducting larger controlled trials. TPE continues to be used, but is a costly therapy with common adverse effects. Uncertainty remains over how to compare the different TPE methods, the optimal dosage of therapy, and monitoring and integration of TPE with other immunotherapies. Further studies are also required to define the indications and benefits of TPE and assess evolving technologies such as immunoadsorption. WHAT THIS PAPER ADDS Studies investigating therapeutic plasma exchange (TPE) are small and mainly uncontrolled. They provide evidence for the efficacy of TPE in childhood neuro-inflammatory conditions. TPE is generally well tolerated provided key adverse effects are anticipated and avoided. Systematic dosing and objective assessment of treatment effect should be priorities for future research.
Collapse
Affiliation(s)
- Michael Eyre
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Yael Hacohen
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK.,Department of Neuroinflammation, Queen Square MS Centre, UCL Institute of Neurology, London, UK
| | - Carmen Barton
- Children's Kidney Service, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| |
Collapse
|
12
|
Ruet A. Update on pediatric-onset multiple sclerosis. Rev Neurol (Paris) 2018; 174:398-407. [PMID: 29784250 DOI: 10.1016/j.neurol.2018.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 03/29/2018] [Accepted: 04/04/2018] [Indexed: 12/29/2022]
Abstract
Pediatric-onset multiple sclerosis (POMS) has distinctive features compared with adult-onset multiple sclerosis (AOMS), and warrants caution despite being a rare form of MS. POMS diagnostic criteria are somewhat different from those used in AOMS, with acute disseminated encephalomyelitis being a key differential diagnosis of MS in children. Other differential diagnoses that have to be ruled out before diagnosing MS include demyelinating syndromes, autoimmune and systemic pathologies, and infectious, genetic, metabolic and neoplastic diseases. Compared with AOMS, POMS has several different clinical, biological and imaging findings. At onset, high-level inflammatory activity is mainly reported, and patients with POMS are also at high risk of developing early physical disabilities and early cognitive impairment. Yet, treating patients with POMS is challenging due to a lack of randomized controlled trials. Some of the disease-modifying drugs currently prescribed are analogous to therapies used in adults, and are associated with good tolerability in pediatric patients. However, a few clinical trials dedicated to POMS are now in progress, and the future outlook is to improve the long-term prognosis of POMS patients with early effective and safe treatments.
Collapse
Affiliation(s)
- A Ruet
- University of Bordeaux, 146, rue Léo Saignat, 33076 Bordeaux cedex, France; Inserm U1215, neurocentre Magendie, 146, rue Léo Saignat, 33000 Bordeaux, France; Hospital of Bordeaux, place Amélie Raba Léon, 33076 Bordeaux cedex, France.
| |
Collapse
|
13
|
Amini Harandi A, Esfandani A, Pakdaman H, Abbasi M, Sahraian MA. Balo’s concentric sclerosis: an update and comprehensive literature review. Rev Neurosci 2018; 29:873-882. [DOI: 10.1515/revneuro-2017-0096] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 03/10/2018] [Indexed: 12/17/2022]
Abstract
Abstract
Balo’s concentric sclerosis (BCS) is considered a variant of multiple sclerosis characterized by concentric lamella of alternating demyelinated and partially myelinated tissues. It is a rare and a relatively acute condition. Attacks may proceed rapidly over weeks or months, typically without remission, like Marburg’s variant, resulting in death or severe disability. However, the majority of cases have a more benign, self-limiting course with spontaneous remission. Magnetic resonance imaging is a primary imaging modality in the diagnosis of BCS. Treatment with intense immunosuppression may be indicated in patients with more aggressive form. New reports reveal more evidence regarding the pathophysiology and treatment strategies.
Collapse
Affiliation(s)
- Ali Amini Harandi
- Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran 1333635445 , Iran
| | - Akram Esfandani
- Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran 1333635445 , Iran
| | - Hossein Pakdaman
- Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran 1333635445 , Iran
| | - Mehdi Abbasi
- Brain Mapping Research Center , Shahid Beheshti University of Medical Sciences , Tehran 1333635445 , Iran
| | - Mohammad Ali Sahraian
- MS Research Center, Neuroscience Institute , Tehran University of Medical Sciences , Tehran 1136746911 , Iran
| |
Collapse
|
14
|
Abstract
BACKGROUND Pediatric-onset multiple sclerosis (POMS) prevalence and incidence rates are increasing globally. No disease-modifying therapy are approved for MS pediatric population. Hence, we aim to review the literature on POMS to guide treating physicians on the current understanding of diagnosis and management of pediatric MS. METHODS The authors performed a literature search and reviewed the current understanding on risk factors and disease parameters in order to discuss the challenges in assessing and implementing diagnosis and therapy in clinical practice. RESULTS The revised International Pediatric MS group diagnostic criteria improved the accuracy of diagnosis. Identification of red flags and mimickers (e.g. acute disseminated encephalomyelitis and neuromyelitis optica) are vital before establishing a definitive diagnosis. Possible etiology and mechanisms including both environmental and genetic risk factors are highlighted. Pediatric MS patients tend to have active inflammatory disease course with a tendency to have brainstem / cerebellar presentations at onset. Due to efficient repair mechanisms at early life, pediatric MS patients tend to have longer time to reach EDSS 6 but reach it at earlier age. Although no therapeutic randomized clinical trials were conducted in pediatric cohorts, open-label multi-center studies reported efficacy and safety results with beta interferons, glatiramer acetate and natalizumab in similar adult cohorts. Several randomized clinical trials assessing the efficacy and safety of oral disease-modifying therapies are ongoing in pediatric MS patients. CONCLUSION Pediatric MS has been increasingly recognized to have a more inflammatory course with frequent infratentorial presentations at onset, which would have important implications in the future management of pediatric cohorts while awaiting the results of ongoing clinical trials.
Collapse
Affiliation(s)
- Raed Alroughani
- Division of Neurology, Department of Medicine, Amiri Hospital, Arabian Gulf Street, 13041, Sharq, Kuwait.
| | - Alexey Boyko
- Department of Neurology, Neurosurgery and Medical Genetic of the Pirogov's Russian National Research Medical University and MS Clinic at the Usupov's Hospital, Ostrovitianov str. 1, Moscow, 117997, Russia
| |
Collapse
|
15
|
|
16
|
Absoud M, Parslow RC, Wassmer E, Hemingway C, Duncan HP, Cummins C, Lim MJ. Severe acute disseminated encephalomyelitis: a paediatric intensive care population-based study. Mult Scler 2017; 17:1258-61. [DOI: 10.1177/1352458510382554] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is a paucity of literature on the epidemiology of severe acute disseminated encephalomyelitis (ADEM). We describe a Paediatric Intensive Care Unit (PICU) population-based study to determine the epidemiology and clinical characteristics of children with ADEM requiring PICU admission or resulting in death. Anonymized data from the Paediatric Intensive Care Audit Network (PICANet) were obtained for all children under 16 years with a diagnosis of ADEM admitted to 25 PICUs in England and Wales (2004–2008). The Office for National Statistics (ONS) mortality database was also searched. In total, 27 PICANet cases (13 females:14 males; median age 4.8 years) were ascertained and all were alive on discharge. In addition, three cases were identified from the ONS mortality database. Of the 27 PICANet cases, clinical features included; seizures ( n = 5); upper airway respiratory obstruction/stridor ( n = 2); unspecified encephalopathy ( n = 27); and polyfocal neurological deficits ( n = 6). The median duration of ventilation was 3 days. Inotropic support was required in 4/27 patients, and one patient had invasive intracranial pressure monitoring. None received plasmapheresis. We conclude that the incidence of childhood ADEM admitted to the PICU in England and Wales is approximated at 0.5 per million children/year, thus representing approximately one quarter of children admitted with ADEM (denominator: 2009 Canadian surveillance data).
Collapse
Affiliation(s)
- M Absoud
- Institute of Child Health, Birmingham Children’s Hospital, Birmingham, UK
| | - RC Parslow
- Paediatric Epidemiology Group, Division of Epidemiology & Biostatistics, University of Leeds, Leeds, UK
| | - E Wassmer
- Paediatric Neurology Department, Birmingham Children’s Hospital, Birmingham, UK
| | - C Hemingway
- Paediatric Neurology Department, Great Ormond Street Hospital, London, UK
| | - HP Duncan
- Paediatric Intensive Care, Birmingham Children’s Hospital, Birmingham, UK
| | - C Cummins
- Institute of Child Health, Birmingham Children’s Hospital, Birmingham, UK
| | - MJ Lim
- Paediatric Neurology Department, The Evelina Children’s Hospital at Guys and St Thomas’ NHS Foundation Trust, London, UK
| | | |
Collapse
|
17
|
A Potential Life-Threatening Reaction to Glatiramer Acetate in Rett Syndrome. Pediatr Neurol 2017; 68:40-43. [PMID: 28254244 DOI: 10.1016/j.pediatrneurol.2016.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 11/23/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Rett syndrome is an X-linked dominant neurodevelopmental disorder manifesting with severe intellectual disability in females caused by various mutations in the MECP2 gene. Brain-derived neurotrophic factor (BDNF) is one of the main proteins regulated by the MECP2 protein; its overexpression in the MeCP2 mouse model partially corrects the Rett phenotype. Pharmacologic manipulations that lead to increased BDNF in individuals with Rett syndrome are expected to have a positive effect on the disorder. Glatiramer acetate, a well-known and safe multiple sclerosis immune modulator, increases BDNF levels in multiple sclerosis animal models and patients responding to treatment, as well as in Rett mouse models. METHODS Fourteen patients with mutation-proven Rett syndrome were recruited for a clinical trial with glatiramer acetate. Baseline data and follow-up data were collected during the trial, which had to be stopped because of a severe adverse event. Our objective is to describe this unexpected potentially life-threatening event in response to glatiramer in patients with Rett syndrome. RESULTS Four of 14 patients with Rett syndrome who were recruited and treated with daily injections of glatiramer acetate as part of an open-label clinical trial developed an exaggerated immediate postinjection response, which was experienced as life threatening in three of the patients, necessitating arrest of the trial. CONCLUSION Despite the known safety profile of glatiramer acetate in adult and pediatric patients with multiple sclerosis, its use in Rett syndrome should be cautiously reconsidered. The described severe adverse event can be related to these patients' primary autonomic nervous system dysfunction.
Collapse
|
18
|
Bykova OV, Nankina IA, Drozdova IM, Kvasova OV, Batysheva TT, Boiko AN. Disease-modifying drugs in pediatric patients with multiple sclerosis. Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:44-53. [DOI: 10.17116/jnevro20161162244-53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
19
|
Nationwide Incidence of Acquired Central Nervous System Demyelination in Icelandic Children. Pediatr Neurol 2015; 53:503-7. [PMID: 26463471 DOI: 10.1016/j.pediatrneurol.2015.08.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/27/2015] [Accepted: 08/28/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Recognizing acquired demyelinating syndromes and multiple sclerosis is important to commence early treatment. The objective of this study was to describe the incidence of acquired demyelinating syndromes and multiple sclerosis among the entire Icelandic pediatric population according to recently promoted criteria. PATIENTS AND METHODS The study included all children in Iceland (<18 years) with acquired demyelinating syndromes and multiple sclerosis from 1990 to 2009 with a minimum of 5-year follow-up. Clinical data were gathered and radiological images reviewed. The cohort included all patients with acquired demyelinating syndromes and multiple sclerosis in the Icelandic pediatric population. RESULTS Eighteen patients with acquired demyelinating syndromes and multiple sclerosis were included, the total annual incidence being 1.15/100,000 (acquired demyelinating syndromes 1.02 and multiple sclerosis 0.45/100,000). The median age at diagnosis was 14.25 years (range 1.25-17.5 years). Thirteen patients were initially diagnosed with clinically isolated syndrome, two had acute disseminated encephalomyelitis, two had multiple sclerosis, and one had neuromyelitis optica. Seven children were diagnosed with multiple sclerosis; three patients with clinically isolated syndrome developed multiple sclerosis after the age of 18 and were not included in the multiple sclerosis group. The gender ratio was equal. Of the nine girls, seven were diagnosed with clinically isolated syndrome. Most patients (11 of 18) were diagnosed during the period January through March. Oligoclonal bands in cerebrospinal fluid were exclusively found in patients with multiple sclerosis and clinically isolated syndrome and 13 of 14 available magnetic resonance images revealed clear abnormalities. CONCLUSION The annual incidence of acquired demyelinating syndromes and multiple sclerosis in Iceland was 1.15/100,000 children. The risk of progression from clinically isolated syndrome to multiple sclerosis was high. There was no female preponderance.
Collapse
|
20
|
Gulati S, Chakrabarty B, Kumar A, Jain P, Patel H, Saini L. Acquired demyelinating disorders of central nervous system: A pediatric cohort. Ann Indian Acad Neurol 2015; 18:S48-55. [PMID: 26538849 PMCID: PMC4604698 DOI: 10.4103/0972-2327.164829] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: This is a retrospective chart review of consecutive children with acquired demyelinating disorders presenting to a north Indian tertiary care hospital over 4 years. The aim of this review is to describe all the patients (with single event as well as those with recurrences) with detailed description of those who recurred. Materials and Methods: Overall 35 cases were reviewed and their clinical presentations, diagnosis, management, and follow-up are being presented. Results: Out of 35 cases, 24 did not show any recurrences (seven acute disseminated encephalomyelitis (ADEM) and 17 clinically isolated syndromes). Amongst the 11 patients with recurrent demyelination, majority were multiple sclerosis (8/11, 72.7%) followed by neuromyelitis optica (NMO; 2/11), and multiphasic ADEM (1/11). The median disease duration and follow-up since onset for those with recurrent episodes is 4 years (2.5-4.5 years). Steroids caused significant improvement in acute episodes of demyelination. However, recurrent demyelinating disorders like multiple sclerosis and NMO required long-term immunomodulation. Azathioprine currently is the most favored long-term immunomodulator used in NMO. Interferon-β and glatiramer acetate are currently recommended for multiple sclerosis. However, azathioprine may be a suitable alternative in a resource-limited setting. Conclusion: The consensus definitions for these groups of disorders need further validation in the pediatric age group. Studies with larger population size are required to characterize features that predict future recurrences.
Collapse
Affiliation(s)
- Sheffali Gulati
- Department of Pediatrics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Biswaroop Chakrabarty
- Department of Pediatrics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radio-Diagnosis, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Puneet Jain
- Department of Pediatrics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Harsh Patel
- Department of Pediatrics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Lokesh Saini
- Department of Pediatrics, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
21
|
Hinton D, Kirk S. Paediatric multiple sclerosis: a qualitative study of families' diagnosis experiences. Arch Dis Child 2015; 100:623-9. [PMID: 25552262 DOI: 10.1136/archdischild-2014-306523] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 12/08/2014] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To examine children's and parents' experiences of obtaining a diagnosis of paediatric multiple sclerosis (MS) and identify potential facilitators and barriers to early diagnosis. DESIGN Qualitative, semi-structured interviews conducted face-to-face in home settings with 31 parents and 21 children and adolescents (8-17 years old) with a clinical diagnosis of MS. Participants were recruited from 16 NHS Trusts and four MS voluntary organisations in the UK. Interviews were recorded and transcribed verbatim and analysed using the constant comparative method. RESULTS Time to diagnosis ranged from 1 to 96 months (median 11.5, mean 23.3, SD 27.3). The findings suggest that delayed presentation to healthcare services, generalists' assumptions about the nature of reported symptoms, lack of awareness of paediatric MS and delayed referral to specialists in paediatric MS were barriers to early investigation and accurate diagnosis. Children, adolescents and parents felt that their concerns about the child's health were not always taken seriously during medical consultations and that clinicians could be reluctant to diagnose MS in childhood. This created additional uncertainty about the child's condition and long-term prognosis. CONCLUSIONS Obtaining a diagnosis of paediatric MS can be a challenging and lengthy process with potentially adverse implications for the health of children/adolescents. Valuing families' knowledge and experience of their child's health, performing a thorough medical examination early in the disease course and organising prompt referrals may aid the early investigation and diagnosis of this disease. In view of the diagnostic challenges, children/adolescents with suspected MS would benefit from early referrals to specialists in paediatric MS.
Collapse
Affiliation(s)
- Denise Hinton
- University of Manchester, School of Nursing, Midwifery and Social Work, Manchester, UK
| | - Susan Kirk
- University of Manchester, School of Nursing, Midwifery and Social Work, Manchester, UK
| |
Collapse
|
22
|
Mühlhausen J, Kitze B, Huppke P, Müller GA, Koziolek MJ. Apheresis in treatment of acute inflammatory demyelinating disorders. ATHEROSCLEROSIS SUPP 2015; 18:251-6. [DOI: 10.1016/j.atherosclerosissup.2015.02.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
23
|
Carvalho LSC, Matta APC, Nascimento OJM, Guimarães AS, Rodrigues LR. Prevalence of temporomandibular disorders symptoms in patients with multiple sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 72:422-5. [PMID: 24964107 DOI: 10.1590/0004-282x20140059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 03/24/2014] [Indexed: 11/21/2022]
Abstract
The aim of the present study was to assess the prevalence of symptoms of temporomandibular disorders (TMD) in patients with the relapsing-remitting form of multiple sclerosis (MS), the relationship between TMD and the severity of MS, and the presence of TMD symptoms in the evaluated groups. Sixty individuals were evaluated: 30 patients diagnosed with relapsing-remitting MS and 30 control individuals matched for gender and age range with no neurologic pathology. In order to investigate the TMD symptoms, the questionnaires of the EACD (European Academy of Craniomandibular Disorders) and the RDC/TMD (Research Diagnostic Criteria for Temporomandibular Disorders), both validated for TMD research, were administered. To assess the extent of disability produced by MS, the Expanded Disability Status Scale (EDSS) was used. The prevalence of TMD symptoms in patients with MS was 56.7% versus 16.7% for the control group, with a statistically significant difference between the groups (p=0.0016). No correlation was found between the severity of MS and the prevalence of TMD symptoms (Fisher's test, p=1.0).
Collapse
|
24
|
Abstract
Baló's concentric sclerosis is often regarded as a rare variant of multiple sclerosis. Patients with this disorder present with acute or subacute neurological deterioration, with MRI showing one or more concentrically multilayered ring-like lesions usually in the cerebral white matter. Historically, Baló's concentric sclerosis was thought fatal in all cases. However, the availability of MRI has led to a better appreciation of the variable natural history of patients presenting with radiologically evident Baló lesions and the clinical association with multiple sclerosis and, less often, with other neurological disorders. Important advances have increased understanding of the immunopathogenic mechanisms associated with the formation of Baló lesions. However, how to treat an acute lesion and when or whether to start treatment are less well understood, although for patients with Baló lesions who also fulfil standard diagnostic criteria for multiple sclerosis, our opinion is that treatment with multiple sclerosis disease-modifying therapy would seem reasonable.
Collapse
Affiliation(s)
- Todd A Hardy
- Neuroimmunology Clinic, Department of Neurology, Concord Repatriation General Hospital, University of Sydney, NSW, Australia; MS Australia Clinic, Brain and Mind Research Institute, Sydney, NSW, Australia.
| | - David H Miller
- Department of Neuroinflammation, University College London Institute of Neurology, Queen Square MS Centre, London, UK
| |
Collapse
|
25
|
Monaco MCG, Major EO. The link between VLA-4 and JC virus reactivation. Expert Rev Clin Immunol 2014; 8:63-72. [DOI: 10.1586/eci.11.85] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
26
|
|
27
|
Tenembaum SN. Treatment of multiple sclerosis and neuromyelitis optica in children and adolescents. Clin Neurol Neurosurg 2013; 115 Suppl 1:S21-9. [DOI: 10.1016/j.clineuro.2013.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
28
|
Erol I, Özkale Y, Alkan Ö, Alehan F. Acute disseminated encephalomyelitis in children and adolescents: a single center experience. Pediatr Neurol 2013; 49:266-73. [PMID: 23849604 PMCID: PMC7127658 DOI: 10.1016/j.pediatrneurol.2013.03.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 03/11/2013] [Accepted: 03/25/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute disseminated encephalomyelitis is an immune-mediated disease that produces multiple inflammatory lesions in the brain and spinal cord. METHODS This study retrospectively evaluated 15 children with acute disseminated encephalomyelitis in children and adolescents from a single institution in Adana, Turkey. RESULTS The patients presented in a seasonal distribution, with 73.3%: (11/15) presenting in winter or spring. The majority of patients (13/15, 86.7%) had a history of acute febrile illness 2 to 40 days before presentation, and five children had serologic evidence of specific triggers: mycoplasma (2 children), influenza-A (H1N1) (1 child), or Epstein-Barr virus. All children were treated with a standard protocol of 3 to 5 days of intravenous administration of methylprednisolone and intravenous immunoglobulin for patients who continued to deteriorate. Oseltamivir and clarithromycin were administered in patients with influenza-A (H1N1) and mycoplasma according to the serology. In 13 patients, all neurologic signs and symptoms resolved after treatment. Only one patient was left with severe neurologic sequelae and another child had recurrent attacks and was ultimately diagnosed with possible multiple sclerosis. CONCLUSIONS The present series demonstrates that acute disseminated encephalomyelitis in children occurs predominantly in winter or spring and often follows an upper respiratory tract illness for those along the southern coast of Anatolia (Mediterranean region). Early treatment with immunomodulative agents is recommended and is likely to result in a favorable outcome or full recovery. This study also suggests benefit from antiviral and antibiotic treatment initiated as soon as possible after the onset of illness.
Collapse
Affiliation(s)
- Ilknur Erol
- Department of Pediatrics, Neurology Division, Adana Teaching and Medical Research Center, Adana, Turkey.
| | - Yasemin Özkale
- Department of Pediatrics, Adana Teaching and Medical Research Center, Adana, Turkey
| | - Özlem Alkan
- Department of Radiology, Adana Teaching and Medical Research Center, Adana, Turkey
| | - Fusun Alehan
- Department of Pediatrics, Division of Child Neurology, Ankara, Turkey
| |
Collapse
|
29
|
Marcus JF, Waubant EL. Updates on clinically isolated syndrome and diagnostic criteria for multiple sclerosis. Neurohospitalist 2013; 3:65-80. [PMID: 23983889 DOI: 10.1177/1941874412457183] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Clinically isolated syndrome (CIS) is a central nervous system demyelinating event isolated in time that is compatible with the possible future development of multiple sclerosis (MS). Early risk stratification for conversion to MS helps with treatment decisions. Magnetic resonance imaging (MRI) is currently the most useful tool to evaluate risk. Cerebrospinal fluid studies and evoked potentials may also be used to assess the likelihood of MS. Four clinical trials evaluating the benefits of either interferon β (IFN-β) or glatiramer acetate (GA) within the first 3 months after a high-risk CIS demonstrate decreased rates of conversion to clinically definite MS (CDMS) and a lesser degree of MRI progression with early treatment. In the 3-, 5-, and 10-year extension studies of 2 formulations of IFN-β, the decreased conversion rate to CDMS remained meaningful when comparing early treatment of CIS to treatment delayed by a median of 2 to 3 years. Diagnostic criteria have been developed based on the clinical and MRI follow-up of large cohorts with CIS and provide guidance on how to utilize clinical activity in combination with radiographic information to diagnose MS. The most recent 2010 McDonald criteria simplify requirements for dissemination in time and space and allow for diagnosis of MS from a baseline brain MRI if there are both silent gadolinium-enhancing lesions and nonenhancing lesions on the same imaging study. The diagnostic criteria for MS require special consideration in children at risk for acute disseminated encephalomyelitis (ADEM), in older adults who may have small vessel ischemic disease, and in ethnic groups that more commonly develop neuromyelitis optica (NMO).
Collapse
|
30
|
Verhey LH, Signori A, Arnold DL, Bar-Or A, Sadovnick AD, Marrie RA, Banwell B, Sormani MP. Clinical and MRI activity as determinants of sample size for pediatric multiple sclerosis trials. Neurology 2013; 81:1215-21. [PMID: 23966255 DOI: 10.1212/wnl.0b013e3182a6cb9b] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To estimate sample sizes for pediatric multiple sclerosis (MS) trials using new T2 lesion count, annualized relapse rate (ARR), and time to first relapse (TTFR) endpoints. METHODS Poisson and negative binomial models were fit to new T2 lesion and relapse count data, and negative binomial time-to-event and exponential models were fit to TTFR data of 42 children with MS enrolled in a national prospective cohort study. Simulations were performed by resampling from the best-fitting model of new T2 lesion count, number of relapses, or TTFR, under various assumptions of the effect size, trial duration, and model parameters. RESULTS Assuming a 50% reduction in new T2 lesions over 6 months, 90 patients/arm are required, whereas 165 patients/arm are required for a 40% treatment effect. Sample sizes for 2-year trials using relapse-related endpoints are lower than that for 1-year trials. For 2-year trials and a conservative assumption of overdispersion (ϑ), sample sizes range from 70 patients/arm (using ARR) to 105 patients/arm (TTFR) for a 50% reduction in relapses, and 230 patients/arm (ARR) to 365 patients/arm (TTFR) for a 30% relapse reduction. Assuming a less conservative ϑ, 2-year trials using ARR require 45 patients/arm (60 patients/arm for TTFR) for a 50% reduction in relapses and 145 patients/arm (200 patients/arm for TTFR) for a 30% reduction. CONCLUSION Six-month phase II trials using new T2 lesion count as an endpoint are feasible in the pediatric MS population; however, trials powered on ARR or TTFR will need to be 2 years in duration and will require multicentered collaboration.
Collapse
Affiliation(s)
- Leonard H Verhey
- From the Pediatric Demyelinating Disease Program (L.H.V.), Program in Neuroscience & Mental Health, The Hospital for Sick Children, University of Toronto, Canada; Biostatistics Unit (A.S., M.P.S.), Department of Health Sciences, University of Genova, Italy; Department of Neurology & Neurosurgery (D.L.A., A.B.-O.), Montreal Neurological Institute and Hospital, McGill University, Montreal; Department of Neurology and Division of Medical Genetics (A.D.S.), University of British Columbia, Vancouver; Departments of Internal Medicine and Community Health Sciences (R.A.M.), Winnipeg Health Sciences Centre, University of Manitoba, Winnipeg, Canada; and Division of Neurology (B.B.), Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Tenembaum SN, Banwell B, Pohl D, Krupp LB, Boyko A, Meinel M, Lehr L, Rocak S, Cantogno EVD, Moraga MS, Ghezzi A. Subcutaneous interferon Beta-1a in pediatric multiple sclerosis: a retrospective study. J Child Neurol 2013; 28:849-56. [PMID: 23666046 DOI: 10.1177/0883073813488828] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To expand current knowledge, we examined the safety and tolerability of subcutaneous interferon β-1a in patients with pediatric-onset multiple sclerosis. Records from 307 patients who had received at least 1 injection of subcutaneous interferon β-1a for demyelinating events when aged younger than 18 years were reviewed. Overall, 168 (54.7%) patients had at least 1 prespecified medical event related to or under close monitoring with subcutaneous interferon β-1a or specific to pediatric patients, 184 (59.9%) had nonserious medical events related to treatment or of unknown causality, and 12 (3.9%) had serious medical events irrespective of causality. The most common laboratory abnormalities were increased alanine (74/195; 37.9%) and aspartate aminotransferase levels (59/194; 30.4%). Annualized relapse rates were 1.79 before treatment and 0.47 during treatment. In conclusion, adult doses of subcutaneous interferon β-1a (44 and 22 μg, 3 times weekly) were well tolerated in pediatric patients and were associated with reduced relapse rates.
Collapse
Affiliation(s)
- Silvia N Tenembaum
- Hospital de Pediatría S.A.M.I.C. Prof Juan P Garrahan, Buenos Aires, Argentina.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Hartung HP, Haas J, Meergans M, Tracik F, Ortler S. [Interferon-β1b in multiple sclerosis therapy: more than 20 years clinical experience]. DER NERVENARZT 2013; 84:679-704. [PMID: 23669866 DOI: 10.1007/s00115-013-3781-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The introduction of interferon-β1b in 1993 in the USA and 2 years later in Europe made it possible for the first time to alter the course of the disease in patients with relapsing-remitting multiple sclerosis (MS). Subsequently, interferon-β1b was approved for the treatment of patients with active secondary progressive MS (1999) and early relapsing-remitting MS following a first demyelinating event (clinically isolated syndrome, CIS) (2006). Here we provide an overview of the clinical experience gathered during more than 20 years of interferon-β use focusing on long-term efficacy and safety and the impact of early initiation of treatment. Furthermore, the following aspects will be discussed: putative mechanisms of action of interferon-β, indications for a disease-modifying therapy, clinical relevance of neutralizing antibodies, importance of adherence in MS therapy, high versus low frequency therapy, combination therapies with interferon-β and safety of interferon-β in children and adolescents with MS and during pregnancy.
Collapse
Affiliation(s)
- H-P Hartung
- Neurologische Klinik im UKD, Medizinische Fakultät, Heinrich-Heine Universität, Moorenstr. 5, 40225 Düsseldorf, Deutschland.
| | | | | | | | | |
Collapse
|
33
|
Rubin JP, Kuntz NL. Diagnostic Criteria for Pediatric Multiple Sclerosis. Curr Neurol Neurosci Rep 2013; 13:354. [DOI: 10.1007/s11910-013-0354-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
34
|
Koziolek M, Mühlhausen J, Friede T, Ellenberger D, Sigler M, Huppke B, Gärtner J, Müller GA, Huppke P. Therapeutic Apheresis in Pediatric Patients with Acute CNS Inflammatory Demyelinating Disease. Blood Purif 2013; 36:92-7. [DOI: 10.1159/000354077] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 06/19/2013] [Indexed: 11/19/2022]
|
35
|
Kuni BJ, Banwell BL, Till C. Cognitive and Behavioral Outcomes in Individuals With a History of Acute Disseminated Encephalomyelitis (ADEM). Dev Neuropsychol 2012; 37:682-96. [DOI: 10.1080/87565641.2012.690799] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
36
|
Spiro DB. Early onset multiple sclerosis: a review for nurse practitioners. J Pediatr Health Care 2012; 26:399-408. [PMID: 23099306 DOI: 10.1016/j.pedhc.2011.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 02/14/2011] [Accepted: 02/14/2011] [Indexed: 10/18/2022]
Abstract
Research demonstrates that 3.5% to 5% of persons with multiple sclerosis (MS) present before the age of 18 years. MS can present in early childhood through adolescence and must be considered as a differential diagnosis in patients with motor impairment, sensory changes, and cognitive disability. The diagnosis of early-onset MS is based on findings from a complete history and physical examination along with brain and spine imaging. The purpose of this article is to review recent literature on early-onset MS and offer suggestions or clinical practice in the identification and management of patients with this debilitating disease.
Collapse
|
37
|
Johnston J, So TY. First-line disease-modifying therapies in paediatric multiple sclerosis: a comprehensive overview. Drugs 2012; 72:1195-211. [PMID: 22642799 DOI: 10.2165/11634010-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Paediatric multiple sclerosis (MS) is defined as the onset of MS before the age of 18 years. Immunomodulatory disease-modifying therapies (i.e. the interferons [IFNs] and glatiramer acetate) are considered first-line treatments in adult patients with MS, but they are largely understudied in the paediatric population. IFNβ is a type 1 IFN produced by fibroblasts. The therapeutic effect achieved by IFNβ in MS is believed to be the result of a variety of mechanisms, including the inhibition of T-cell proliferation and a shift in cytokine production. There are currently two forms of recombinant IFNβ used therapeutically for MS: IFNβ-1a and IFNβ-1b. Two formulations of IFNβ-1a exist, one administered as an intramuscular injection once weekly and the other by subcutaneous injection three times per week. Only one type of IFNβ-1b product is on the market, a subcutaneous injection administered every other day. Pharmacokinetic studies of these agents in children do not exist and available data are primarily from studies in healthy adults. It does not appear that the various formulations differ significantly in terms of bioavailability or efficacy in adults. The toxicity profiles of the interferon formulations are similar, with the most common adverse effects in children including flu-like symptoms, injection site reactions and transient elevations in liver enzymes. Glatiramer acetate is a mixture of synthetic polypeptide chains consisting of four different amino acids. Glatiramer acetate appears to mimic the antigenic properties of myelin basic protein (MBP), and by doing so, alters T-cell activation in the periphery. Glatiramer acetate is administered as a once-daily subcutaneous injection. Similar to the IFNβ formulations, there are no pharmacokinetic studies of this agent in children. The most common adverse effects include injection site reactions and transient chest tightness. Fingolimod, a sphingosine 1-phosphate receptor modulator, is a new disease-modifying therapy that was approved by the US FDA in 2010 for the first-line treatment of relapsing forms of MS in adults. However, due to a lack of information and clinical data on this agent in the paediatric population, it is not included in this discussion. Dose-finding studies of the IFNs and glatiramer acetate in the paediatric population are limited. Dosing recommendations are largely based on tolerability studies, with most children and adolescents tolerating the full adult doses. Clinical studies of IFNs in children have not been objectively designed to establish the efficacy of these therapies, and evidence is limited to that of observational trials and retrospective case reports. However, the largest cohort (130 cases) of paediatric MS patients studied to date reported a reduction in annual relapse rate with all three of the different IFNβ formulations and glatiramer acetate after a follow-up period of more than 4 years. Treatment with one of the first-line agents should be offered to any patient after the occurrence of a second demyelinating episode. The efficacy of the four first-line disease-modifying agents is considered to be relatively equivalent, and the choice of agent should be determined on an individual patient basis, taking into account potential adverse effects and patient preferences. Current data suggest that the IFNs and glatiramer acetate are safe and effective therapies in paediatric patients with MS. However, further studies evaluating the pharmacokinetics, appropriate dosing and comparisons of efficacy among these agents are needed to determine the most appropriate and evidence-based treatment decisions in this population.
Collapse
Affiliation(s)
- Jessica Johnston
- University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | | |
Collapse
|
38
|
Abstract
OPINION STATEMENT Pediatric optic neuritis is a rare disorder causing a subacute loss of vision (often bilateral) in children, often of a severe degree. Common clinical findings include dense visual field loss, afferent pupillary defect (APD) in unilateral cases, and papillitis that is often bilateral. Contrary to optic neuritis in the adult population, the differential diagnosis for this disorder in pediatric patients is quite extensive, so neuroimaging and serologic evaluation are necessary to exclude an infectious or neoplastic process. Pediatric optic neuritis may occur as a clinically isolated syndrome, or in association with diffuse neurologic dysfunction, such as acute disseminated encephalomyelitis (ADEM). Optic neuritis may also be the first episode heralding the onset of pediatric multiple sclerosis or neuromyelitis optica (NMO or Devic's disease). Therefore, formal neurologic evaluation and follow-up are indicated. Although the management of this disorder in adults is well described, there is a paucity of evidence-based, prospective clinical data on its management and treatment in a pediatric population. The current treatment of pediatric optic neuritis consists of 3 to 5 days of intravenous methylprednisolone (4-30 mg/kg per day), followed by a prolonged oral corticosteroid taper. A prolonged course of oral steroid (2-4 weeks) is recommended to avoid recurrence, which is common in this age group. Some controversy persists concerning the exposure of children to high-dose parenteral corticosteroids to treat an entity that is usually self-limited, but given the severity of vision loss in one or both eyes in this population, this intervention is standard in neuro-ophthalmologic practice.
Collapse
Affiliation(s)
- Gabrielle R Bonhomme
- Eye and Ear Institute, University of Pittsburgh Medical Center, 203 Lothrop Street, Pittsburgh, PA, 15213, USA,
| | | |
Collapse
|
39
|
Chitnis T, Tenembaum S, Banwell B, Krupp L, Pohl D, Rostasy K, Yeh EA, Bykova O, Wassmer E, Tardieu M, Kornberg A, Ghezzi A. Consensus statement: evaluation of new and existing therapeutics for pediatric multiple sclerosis. Mult Scler 2011; 18:116-27. [DOI: 10.1177/1352458511430704] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
New therapies are being evaluated by clinical trials and, if efficacious, introduced for the treatment of adult MS. The role of these new and existing agents in the management of pediatric MS has yet to be defined. Pediatric investigation plans are now required by the Food and Drug Administration and European Medicines Agency for approval of new biological agents, providing an important opportunity to gather much-needed data for clinicians caring for children and adolescents with MS. However, challenges include the small number of patients, and the need for efficient yet comprehensive study designs incorporating factors necessary to inform the clinical care of children with MS. The elected Steering committee of the International Pediatric MS Study Group (IPMSSG) conducted a structured review of existing data on the disease-modifying therapies in pediatric MS and developed a consensus statement, which was further modified by the IPMSSG general membership, using an online survey tool. Fifty-one IPMSSG members from 21 countries responded to the survey, and 50 approved the final statement. Consensus recommendations regarding use of existing first- and second-line therapies, as well as a proposed definition for inadequate treatment response, are presented. Recommendations for the use and evaluation of emerging therapies (currently in phase III clinical trials or recently approved for adult MS) are discussed. The IPMSSG endorses the inclusion of pediatric MS patients in trials evaluating appropriate new and emerging therapies. Mechanisms for conducting high-impact, multicenter studies, including long-term follow-up in pediatric MS, are required to ensure that all MS patients, irrespective of age, benefit from advances in MS therapeutics.
Collapse
Affiliation(s)
- T Chitnis
- Partners Pediatric Multiple Sclerosis Center, Massachusetts General Hospital, Boston, MA, USA
| | - S Tenembaum
- National Pediatric Hospital, Dr J P Garrahan, Buenos Aires, Argentina
| | - B Banwell
- The Hospital for Sick Children, University of Toronto, Canada
| | - L Krupp
- Stony Brook University Medical Center, Stony Brook, NY, USA
| | - D Pohl
- Children’s Hospital of Eastern Ontario, University of Ottawa, Canada
| | - K Rostasy
- Department of Pediatrics IV, Division of Pediatric Neurology and Inborn Errors of Metabolism, Innsbruck Medical University, Innsbruck, Austria
| | - E A Yeh
- Department of Neurology, SUNY Buffalo, Buffalo, NY, USA
| | - O Bykova
- Moscow Pediatric Psychoneurological Hospital, Moscow, Russia
| | - E Wassmer
- Birmingham Children’s Hospital, Birmingham, UK
| | - M Tardieu
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre and Université Paris-Sud, Paris, France
| | - A Kornberg
- Royal Children’s Hospital, Melbourne, Australia
| | - A Ghezzi
- Multiple Sclerosis Study Center, Hospital of Gallarate, Gallarate, Italy
| | | |
Collapse
|
40
|
Farfán Albarracín JD, Espitia Segura OM. Esclerosis múltiple en pacientes pediátricos: fisiopatología, diagnóstico y manejo. MEDUNAB 2011. [DOI: 10.29375/01237047.1524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
ResumenObjetivo: Revisar la literatura disponible sobre esclerosis múltiple en la población pediátrica.Métodos: Revisión sistemática de la literatura encontrada en las bases de datos Scopus y PubMed posterior al año 2000.Resultados y Conclusiones: La Esclerosis Múltiple es una enfermedad con una tasa de incidencia de 2 – 4 / 100.000 habitantes en Colombia, de la cual la población pediátrica representa entre 2,7 – 5% de los casos. Las causas que se han atribuido a la enfermedad son múltiples, incluyendo factores ambientales como infecciones virales o bacterianas, exposición a humo de cigarrillo o deficiencia de vitamina D, entre otras, genéticas e inmunológicas. Su diagnóstico se basa en los hallazgos clínicos e imagenológicos, previa exclusión de enfermedades más comunes. Su tratamiento se divide en tres ejes: el tratamiento de eventos agudos, el tratamiento modificador de la enfermedad y el tratamiento sintomático. Para el primero los medicamentos de primera elección son los corticoides, para el segundo los medicamentos inmunomoduladores como Acetato de Glatiramer y para el tercero se debe realizar un enfoque multidisciplinario. Su pronóstico a largo plazo es variable y depende en alguna medida de la respuesta al tratamiento.
Collapse
|
41
|
Bayas A, Penzien J, Hellwig K. Accidental natalizumab administration to the third trimester of pregnancy in an adolescent patient with multiple sclerosis. Acta Neurol Scand 2011; 124:290-2. [PMID: 21943035 DOI: 10.1111/j.1600-0404.2010.01480.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Natalizumab is neither licensed for the use in adolescents nor during pregnancy. There are no reports of accidental natalizumab exposure during pregnancy continued as long as to the third trimester of pregnancy. AIMS We report the outcome of pregnancy in a 17-year-old adolescent patient with multiple sclerosis (MS) treated with natalizumab from the age of 16, who was diagnosed to be pregnant in the 31st gestational week (gw) of pregnancy. To our knowledge, this report describes the first patient receiving natalizumab to the third trimester of pregnancy. CASE REPORT Because of high relapse activity, natalizumab treatment was administered in an adolescent patient with MS. Pregnancy was diagnosed in the 31st gw after 17 natalizumab infusions, seven of them accidentally during pregnancy. RESULTS Pre- and postnatal development of the child was normal. CONCLUSIONS The case reported indicates that accidentally continued natalizumab treatment until few weeks before delivery may have no negative impact on the developing foetus.
Collapse
Affiliation(s)
- A Bayas
- Department of Neurology Klinikum Augsburg, Germany.
| | | | | |
Collapse
|
42
|
Absoud M, Cummins C, Chong WK, De Goede C, Foster K, Gunny R, Hemingway C, Jardine P, Kneen R, Likeman M, Lim MJ, Pike M, Sibtain N, Whitehouse WP, Wassmer E. Paediatric UK demyelinating disease longitudinal study (PUDDLS). BMC Pediatr 2011; 11:68. [PMID: 21798048 PMCID: PMC3163536 DOI: 10.1186/1471-2431-11-68] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 07/28/2011] [Indexed: 11/16/2022] Open
Abstract
Background There is evidence that at least 5% of Multiple sclerosis (MS) cases manifest in childhood. Children with MS present with a demyelinating episode involving single or multiple symptoms prior to developing a second event (usually within two years) to then meet criteria for diagnosis. There is evidence from adult cohorts that the incidence and sex ratios of MS are changing and that children of immigrants have a higher risk for developing MS. A paediatric population should reflect the vanguard of such changes and may reflect trends yet to be observed in adult cohorts. Studying a paediatric population from the first demyelinating event will allow us to test these hypotheses, and may offer further valuable insights into the genetic and environmental interactions in the pathogenesis of MS. Methods/Design The Paediatric UK Demyelinating Disease Longitudinal Study (PUDDLS) is a prospective longitudinal observational study which aims to determine the natural history, predictors and outcomes of childhood CNS inflammatory demyelinating diseases. PUDDLS will involve centres in the UK, and will establish a cohort of children affected with a first CNS inflammatory demyelinating event for long-term follow up by recruiting for approximately 5 years. PUDDLS will also establish a biological sample archive (CSF, serum, and DNA), allowing future hypothesis driven research. For example, the future discovery of a biomarker will allow validation within this dataset for the evaluation of novel biomarkers. Patients will also be requested to consent to be contacted in the future. A secondary aim is to collaborate internationally with the International Paediatric Multiple Sclerosis Study Group when future collaborative studies are proposed, whilst sharing a minimal anonymised dataset. PUDDLS is the second of two jointly funded studies. The first (UCID-SS) is an epidemiological surveillance study that already received ethical approvals, and started on the 1st September 2009. There is no direct patient involvement, and UCID-SS aims to determine the UK and Ireland incidence of CNS inflammatory demyelinating disorders in children under 16 years. Discussion A paediatric population should reflect the vanguard of MS epidemiological changes and may reflect trends yet to be observed in adult MS cohorts. The restricted window between clinical expression of disease and exposure to environmental factors in children offers a unique research opportunity. Studying a paediatric population from the first demyelinating event will allow us to investigate the changing epidemiology of MS, and may offer further valuable insights into the genetic and environmental interactions in the pathogenesis of MS.
Collapse
Affiliation(s)
- Michael Absoud
- School of Health & Population Sciences, University of Birmingham, Birmingham, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Yeh EA, Weinstock-Guttman B. Natalizumab in pediatric multiple sclerosis patients. Ther Adv Neurol Disord 2011; 3:293-9. [PMID: 21179619 DOI: 10.1177/1756285610381526] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Pediatric multiple sclerosis (MS) comprises 2-5% of all cases of MS. Although first-line disease-modifying therapy (DMT) including interferons and glatiramer acetate appear to be well tolerated in this population, recent work has suggested that a growing number of children suffer from disease which is resistant to treatment with these therapies. Natalizumab is a therapy which, although associated with a 1 : 1000 risk for progressive multifocal leukoencephalopathy (PML), has been shown to be well tolerated in the adult population and may lead to disease remission in adults with highly active disease. Reports of use of this therapy in the pediatric population with highly active disease have been published. This paper reviews current experience with the use of natalizumab in the pediatric MS population, with attention to potential risks and possible long-term outcomes in this population.
Collapse
Affiliation(s)
- E Ann Yeh
- Pediatric Multiple Sclerosis and Demyelinating Disorders Center of the Jacobs Neurological Institute, Women and Children's Hospital of Buffalo, and Department of Neurology, State University of New York, Buffalo, NY, USA
| | | |
Collapse
|
44
|
Spalice A, Parisi P, Papetti L, Nicita F, Ursitti F, Del Balzo F, Properzi E, Verrotti A, Ruggieri M, Iannetti P. Clinical and pharmacological aspects of inflammatory demyelinating diseases in childhood: an update. Curr Neuropharmacol 2011; 8:135-48. [PMID: 21119885 PMCID: PMC2923368 DOI: 10.2174/157015910791233141] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 01/19/2010] [Accepted: 02/24/2010] [Indexed: 12/21/2022] Open
Abstract
Inflammatory demyelinating diseases comprise a spectrum of disorders affecting the myelin of the central and peripheral nervous system. These diseases can usually be differentiated on the basis of clinical, radiological, laboratory and pathological findings. Recent studies have contributed to current awareness that inflammatory demyelinating diseases are not restricted to the adult age group, but are more common in pediatric age than previously believed. Some of pediatric inflammatory demyelinating diseases carry an unfavorable long-term prognosis but appropriate treatments can improve the outcome. The possibility of physical and cognitive disability resulting from these diseases, highlights the urgent need for therapeutic strategies for neurorehabilitation, neuroregeneration, and neurorepair. This review discusses characteristics of primary demyelinating diseases more frequently observed in childhood, focusing on epidemiology, clinical aspects and treatments.
Collapse
Affiliation(s)
- Alberto Spalice
- Child Neurology, Paediatric Department, I Faculty of Medicine, "Sapienza University", c/o Policlinico Umberto I, Rome, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Waldman AT, Gorman MP, Rensel MR, Austin TE, Hertz DP, Kuntz NL. Management of pediatric central nervous system demyelinating disorders: consensus of United States neurologists. J Child Neurol 2011; 26:675-82. [PMID: 21518802 PMCID: PMC4154504 DOI: 10.1177/0883073810395141] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Demyelinating diseases are a group of autoimmune inflammatory disorders affecting the central nervous system in adults and children; however, the diagnosis, evaluation, and treatment of these disorders are primarily based on adult data. The purpose of this study was to assess the practice patterns of US physicians who specialize in treating acquired central nervous system demyelinating diseases in children and adolescents. The Delphi technique was used to identify areas of consensus in management and treatment. Forty-two experts in the field participated in the process. Intravenous methylprednisolone was the first-line treatment of choice for acute episodes of all forms of demyelinating disease; however, consensus was lacking regarding specific dose, treatment duration, and use of an oral taper. First-line disease-modifying therapies for pediatric multiple sclerosis were interferons and glatiramer acetate, chosen based on perceived efficacy and tolerability, respectively. Areas lacking agreement among the expert panel and requiring further research are identified.
Collapse
Affiliation(s)
- Amy T. Waldman
- Departments of Pediatrics and Neurology, Children’s Hospital of Philadelphia and Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark P. Gorman
- Department of Neurology, Children’s Hospital Boston and Massachusetts General Hospital, Boston, Massachusetts
| | - Mary R. Rensel
- Department of Neurology, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Nancy L. Kuntz
- Department of Pediatrics, Children’s Memorial Hospital, Chicago, Illinois
| | | |
Collapse
|
46
|
Abstract
Acute central nervous system (CNS) inflammation may occur as a monophasic illness or may represent the first attack of a chronic inflammatory disorder, such as multiple sclerosis, neuromyelitis optica, or CNS vasculitis. We review essential components of the initial assessment, diagnostic workup, acute and chronic management strategies, and research issues pertaining to children with CNS inflammatory diseases and suggest methods for these competencies to be attained during the course of child neurology residency training.
Collapse
|
47
|
Banwell B, Bar-Or A, Giovannoni G, Dale RC, Tardieu M. Therapies for multiple sclerosis: considerations in the pediatric patient. Nat Rev Neurol 2011; 7:109-22. [PMID: 21224883 DOI: 10.1038/nrneurol.2010.198] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Current and emerging therapies for multiple sclerosis (MS) offer promise for improved disease control and long-term clinical outcome. To date, these therapies have been evaluated solely in the context of adult MS. However, onset of MS in children is being increasingly recognized, and recent studies have identified a significant impact of MS onset during childhood on cognitive and physical functioning. Optimization of pediatric MS care requires that promising new therapies be made available to children and adolescents, but also that safety and tolerability and potential influence of therapies on the developing immune and neural networks of pediatric patients be closely considered. We propose care algorithms illustrating models for therapy that detail careful monitoring of pediatric patients with MS, provide definitions for inadequate treatment response and treatment escalation, and foster multinational collaboration in future therapeutic trials.
Collapse
Affiliation(s)
- Brenda Banwell
- Department of Pediatrics, Division of Neurology, The Hospital for Sick Children, University of Toronto, ON, Canada.
| | | | | | | | | |
Collapse
|
48
|
|
49
|
Ghezzi A, Banwell B, Boyko A, Amato MP, Anlar B, Blinkenberg M, Boon M, Filippi M, Jozwiak S, Ketelslegers I, Kornek B, Ming Lim, Lindstrom E, Nadj C, Neuteboom R, Rocca MA, Rostasy K, Tardieu M, Wassmer E, Catsman-Berrevoets C, Hintzen R. Meeting Review: The management of multiple sclerosis in children: a European view. Mult Scler 2010; 16:1258-67. [DOI: 10.1177/1352458510375568] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
About 3—5% of all patients with multiple sclerosis experience the onset of their disease under the age of 16. A significant proportion of paediatric multiple sclerosis patients develop significant cognitive disturbances and persistent physical disability. The high relapse rate and the morbidity in the paediatric multiple sclerosis population has triggered the use of disease-modifying therapies that have been shown to reduce relapse rate, disease progression and cognitive decline in adult patients with multiple sclerosis. Hard evidence for the right treatment and its appropriate timing is scarce in paediatric multiple sclerosis. Nevertheless, expertise in this field has grown thanks to recent open-label trials and experience generated in specialized centres. In spring 2009, a first meeting was held in Rotterdam with clinicians from 11 European countries (one from Canada) that are all active in the management of paediatric multiple sclerosis. One of the aims was to generate a common view on the management of paediatric multiple sclerosis patients. The result of this meeting is presented here to help standardize treatment and to support clinicians with less experience in this field.
Collapse
Affiliation(s)
- Angelo Ghezzi
- Centro Studi SM, H S. Antonio Abate, Gallarate, VA, Italy
| | - Brenda Banwell
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alexey Boyko
- Russian State Medical University, Department of Neurology and Neurosurgery, Moscow, Russia
| | - Maria Pia Amato
- University of Florence, Department of Neurological and Psychiatric Sciences, Florence, Italy
| | - Banu Anlar
- Hacettepe University, Hospital, Department of Pediatric Neurology, Ankara, Turkey
| | - Morten Blinkenberg
- Copenhagen University Hospital, The Neuroscience Centre, Rigshospitalet, Copenhagen, Denmark
| | - Maartje Boon
- University Medical Centre, Groningen, Department of Pediatric Neurology, Groningen, The Netherlands
| | - Massimo Filippi
- University San Raffaele, Neuroimaging Research Unit, Milan, Italy
| | - Sergiusz Jozwiak
- The Children's Memorial Health Institute, Departments of Neurology and Epileptology, Warsaw, Poland
| | | | - Barbara Kornek
- University of Vienna Medical School, Department of Neuropsychiatry of Childhood and Adolescence, Vienna, Austria
| | - Ming Lim
- Evelina's Children's Hospital at Guys and St.Thomas' Hospitals, Department of Pediatric Neurology, London, UK
| | - Eva Lindstrom
- Karolinska Institute, Department of Neurology, Stockholm, Sweden
| | - Congor Nadj
- Institute of Neurology, Novi Sad, Republic of Serbia
| | - Rinze Neuteboom
- Erasmus MC, Department of Neurology, Rotterdam, The Netherlands
| | - Maria A Rocca
- University San Raffaele, Neuroimaging Research Unit, Milan, Italy
| | - Kevin Rostasy
- Medical University Innsbruck, Division of Pediatric Neurology and Inherited Metabolic Disorders, Innsbruck, Austria
| | - Marc Tardieu
- Bicêtre Hospital, Department of Neuropediatrics, University Paris Sud, France
| | | | | | - Rogier Hintzen
- Erasmus MC, Department of Neurology, Rotterdam, The Netherlands,
| |
Collapse
|
50
|
Mah JK, Thannhauser JE. Management of multiple sclerosis in adolescents - current treatment options and related adherence issues. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2010; 1:31-43. [PMID: 24600259 PMCID: PMC3916015 DOI: 10.2147/ahmt.s7594] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Multiple sclerosis (MS) is a progressive inflammatory demyelinating disorder of the central nervous system that is increasingly recognized in children and adolescents. This realization comes with additional concerns about existing therapeutic options and the impact of the disease on health-related outcomes of adolescents with MS. This five-part review provides an update on management strategies relevant to the pediatric MS population. The first section gives an overview on the epidemiology and natural history of early onset MS. The second section outlines currently available MS treatments, including medications during acute relapses and long-term immunomodulatory therapies. The third section highlights adherence issues pertaining to MS, including the challenges uniquely faced by adolescents. The fourth section provides a summary of research into quality of life and psychosocial consequences of pediatric onset MS. Attention is drawn to the grief experience of affected adolescents and the importance of peer relationships. Finally, the family resilience framework is presented as a conceptual model to facilitate optimal adaptation of adolescents with MS. Healthcare professionals can promote resilience and treatment adherence by ensuring that these individuals and their families are sufficiently informed about available MS treatments, providing instrumental support for managing potential medication side effects, and addressing age-appropriate developmental needs.
Collapse
Affiliation(s)
- Jean K Mah
- Division of Neurology, Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer E Thannhauser
- Division of Applied Psychology, Faculty of Education, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|