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Marrie RA, Sormani MP, Apap Mangion S, Bovis F, Cheung WY, Cutter GR, Feys P, Hill MD, Koch MW, McCreary M, Mowry EM, Park JJH, Piehl F, Salter A, Chataway J. Improving the efficiency of clinical trials in multiple sclerosis. Mult Scler 2023; 29:1136-1148. [PMID: 37555492 PMCID: PMC10413792 DOI: 10.1177/13524585231189671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Phase 3 clinical trials for disease-modifying therapies in relapsing-remitting multiple sclerosis (RRMS) have utilized a limited number of conventional designs with a high degree of success. However, these designs limit the types of questions that can be addressed, and the time and cost required. Moreover, trials involving people with progressive multiple sclerosis (MS) have been less successful. OBJECTIVE The objective of this paper is to discuss complex innovative trial designs, intermediate and composite outcomes and to improve the efficiency of trial design in MS and broaden questions that can be addressed, particularly as applied to progressive MS. METHODS We held an international workshop with experts in clinical trial design. RESULTS Recommendations include increasing the use of complex innovative designs, developing biomarkers to enrich progressive MS trial populations, prioritize intermediate outcomes for further development that target therapeutic mechanisms of action other than peripherally mediated inflammation, investigate acceptability to people with MS of data linkage for studying long-term outcomes of clinical trials, use Bayesian designs to potentially reduce sample sizes required for pediatric trials, and provide sustained funding for platform trials and registries that can support pragmatic trials. CONCLUSION Novel trial designs and further development of intermediate outcomes may improve clinical trial efficiency in MS and address novel therapeutic questions.
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Affiliation(s)
- Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sean Apap Mangion
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
| | - Francesca Bovis
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Winson Y Cheung
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Peter Feys
- REVAL Rehabilitation Research Center, REVAL, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium/Universitair MS Centrum, UMSC, Hasselt, Belgium
| | - Michael D Hill
- Departments of Clinical Neurosciences, Community Health Sciences, Medicine, and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marcus Werner Koch
- Departments of Clinical Neurosciences, Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Morgan McCreary
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jay JH Park
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Amber Salter
- Department of Neurology, Section on Statistical Planning and Analysis, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK/Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
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Alharbi MA, Aldosari F, Althobaiti AH, Abdullah FM, Aljarallah S, Alkhawajah NM, Alanazi M, AlRuthia Y. Clinical and economic evaluations of natalizumab, rituximab, and ocrelizumab for the management of relapsing-remitting multiple sclerosis in Saudi Arabia. BMC Health Serv Res 2023; 23:552. [PMID: 37237257 DOI: 10.1186/s12913-023-09462-z] [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: 06/25/2022] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
INTRODUCTION The advent of new disease-modifying therapies (DMTs), such as monoclonal antibodies (mAbs), resulted in significant changes in the treatment guidelines for Multiple sclerosis (MS) and improvement in the clinical outcomes. However, mAbs, such as rituximab, natalizumab, and ocrelizumab, are expensive with variable effectiveness rates. Thus, the present study aimed to compare the direct medical cost and consequences (e.g., clinical relapse, disability progression, and new MRI lesions) between rituximab and natalizumab in managing relapsing-remitting multiple sclerosis (RRMS) in Saudi Arabia. Also, the study aimed to explore the cost and consequence of ocrelizumab in managing RRMS as a second-choice treatment. METHODS The electronic medical records (EMRs) of patients with RRMS were retrospectively reviewed to retrieve the patients' baseline characteristics and disease progression from two tertiary care centers in Riyadh, Saudi Arabia. Biologic-naïve patients treated with rituximab or natalizumab or those switched to ocrelizumab and treated for at least six months were included in the study. The effectiveness rate was defined as no evidence of disease activity (NEDA-3) (i.e., absence of new T2 or T1 gadolinium (Gd) lesions as demonstrated by the Magnetic Resonance Imaging (MRI), disability progression, and clinical relapses), while the direct medical costs were estimated based on the utilization of healthcare resources. In addition, bootstrapping with 10,000 replications and inverse probability weighting based on propensity score were conducted. RESULTS Ninety-three patients met the inclusion criteria and were included in the analysis (natalizumab (n = 50), rituximab (n = 26), ocrelizumab (n = 17)). Most of the patients were otherwise healthy (81.72%), under 35 years of age (76.34%), females (61.29%), and on the same mAb for more than one year (83.87%). The mean effectiveness rates for natalizumab, rituximab, and ocrelizumab were 72.00%, 76.92%, and 58.83%, respectively. Natalizumab mean incremental cost compared to rituximab was $35,383 (95% CI: $25,401.09- $49,717.92), and its mean effectiveness rate was 4.92% lower than rituximab (95% CI: -30-27.5) with 59.41% confidence level that rituximab will be dominant. CONCLUSIONS Rituximab seems to be more effective and is less costly than natalizumab in the management of RRMS. Ocrelizumab does not seem to slow the rates of disease progression among patients previously treated with natalizumab.
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Affiliation(s)
- Mansour A Alharbi
- Department of Pharmacy, King Saud Medical City, Riyadh, 12746, Saudi Arabia
| | - Fahad Aldosari
- Department of Pharmacy, King Saud Medical City, Riyadh, 12746, Saudi Arabia
| | | | - Faris M Abdullah
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, 24382, Saudi Arabia
| | - Salman Aljarallah
- Department of Medicine, Neurology Division, College of Medicine, King Saud University, P.O. Box 3145, Riyadh, 12372, Saudi Arabia
| | - Nuha M Alkhawajah
- Department of Medicine, Neurology Division, College of Medicine, King Saud University, P.O. Box 3145, Riyadh, 12372, Saudi Arabia
| | - Miteb Alanazi
- Department of Pharmacy, King Khalid University Hospital, P.O. Box 3145, Riyadh, 12372, Saudi Arabia
| | - Yazed AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh, 11451, Saudi Arabia.
- Pharmacoeconomics Research Unit, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh, 11451, Saudi Arabia.
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Quan H, Xu Z, Luo J, Paux G, Cho M, Chen X. Utilization of treatment effect on a surrogate endpoint for planning a study to evaluate treatment effect on a final endpoint. Pharm Stat 2023. [PMID: 36866697 DOI: 10.1002/pst.2298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
To design a phase III study with a final endpoint and calculate the required sample size for the desired probability of success, we need a good estimate of the treatment effect on the endpoint. It is prudent to fully utilize all available information including the historical and phase II information of the treatment as well as external data of the other treatments. It is not uncommon that a phase II study may use a surrogate endpoint as the primary endpoint and has no or limited data for the final endpoint. On the other hand, external information from the other studies for the other treatments on the surrogate and final endpoints may be available to establish a relationship between the treatment effects on the two endpoints. Through this relationship, making full use of the surrogate information may enhance the estimate of the treatment effect on the final endpoint. In this research, we propose a bivariate Bayesian analysis approach to comprehensively deal with the problem. A dynamic borrowing approach is considered to regulate the amount of historical data and surrogate information borrowing based on the level of consistency. A much simpler frequentist method is also discussed. Simulations are conducted to compare the performances of different approaches. An example is used to illustrate the applications of the methods.
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Affiliation(s)
- Hui Quan
- Biostatistics and Programming, Sanofi, Bridgewater, New Jersey, USA
| | - Zhixing Xu
- Biostatistics and Programming, Sanofi, Bridgewater, New Jersey, USA
| | - Junxiang Luo
- Biostatistics and Programming, Moderna, Cambridge, Massachusetts, USA
| | - Gautier Paux
- Biostatistics and Programming, Sanofi, Bridgewater, New Jersey, USA
| | - Meehyung Cho
- Biostatistics and Programming, Sanofi, Bridgewater, New Jersey, USA
| | - Xun Chen
- Biostatistics and Programming, Sanofi, Bridgewater, New Jersey, USA
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Machine learning for exploring neurophysiological functionality in multiple sclerosis based on trigeminal and hand blink reflexes. Sci Rep 2022; 12:21078. [PMID: 36473893 PMCID: PMC9726823 DOI: 10.1038/s41598-022-24720-6] [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: 03/22/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
Brainstem dysfunctions are very common in Multiple Sclerosis (MS) and are a critical predictive factor for future disability. Brainstem functionality can be explored with blink reflexes, subcortical responses consisting in a blink following a peripheral stimulation. Some reflexes are already employed in clinical practice, such as Trigeminal Blink Reflex (TBR). Here we propose for the first time in MS the exploration of Hand Blink Reflex (HBR), which size is modulated by the proximity of the stimulated hand to the face, reflecting the extension of the peripersonal space. The aim of this work is to test whether Machine Learning (ML) techniques could be used in combination with neurophysiological measurements such as TBR and HBR to improve their clinical information and potentially favour the early detection of brainstem dysfunctionality. HBR and TBR were recorded from a group of People with MS (PwMS) with Relapsing-Remitting form and from a healthy control group. Two AdaBoost classifiers were trained with TBR and HBR features each, for a binary classification task between PwMS and Controls. Both classifiers were able to identify PwMS with an accuracy comparable and even higher than clinicians. Our results indicate that ML techniques could represent a tool for clinicians for investigating brainstem functionality in MS. Also, HBR could be promising when applied in clinical practice, providing additional information about the integrity of brainstem circuits potentially favouring early diagnosis.
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AlRuthia Y, Balkhi B, Alkhalifah SA, Aljarallah S, Almutairi L, Alanazi M, Alajlan A, Aldhafiri SM, Alkhawajah NM. Real-World Comparative Cost-Effectiveness Analysis of Different Classes of Disease-Modifying Therapies for Relapsing-Remitting Multiple Sclerosis in Saudi Arabia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182413261. [PMID: 34948876 PMCID: PMC8702157 DOI: 10.3390/ijerph182413261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 01/05/2023]
Abstract
The very fact that multiple sclerosis (MS) is incurable and necessitates life-long care makes it one of the most burdensome illnesses. The aim of this study was to compare the cost-effectiveness of orally administered medications (e.g., fingolimod, dimethyl fumarate, and teriflunomide), interferon (IFN)-based therapy, and monoclonal antibodies (MABs) (e.g., natalizumab and rituximab) in the management of relapsing-remitting multiple sclerosis (RRMS) in Saudi Arabia using real-world data. This was a retrospective cohort study in which patients with RRMS aged ≥18 years without any other chronic health conditions with non-missing data for at least 12 months were recruited from the electronic health records of a university-affiliated tertiary care center. Multiple logistic regressions controlling for age, sex, and duration of therapy were conducted to examine the odds of disability progression, clinical relapse, MRI lesions, and composite outcome (e.g., relapse, lesion development on MRI, disability progression). The number of patients who met the inclusion criteria and were included in the analysis was 146. Most of the patients were female (70.51%) and young (e.g., ≤35 years of age). There were 40 patients on the orally administered agents (e.g., dimethyl fumarate, teriflunomide, fingolimod), 66 patients were on IFN-based therapy (e.g., Rebif®), and 40 patients were on monoclonal antibodies (e.g., rituximab and natalizumab). Patients on MABs had lower odds of the composite outcome (OR = 0.17 (95% CI: 0.068–0.428)). The use of orally administered agents was dominant (e.g., more effective and less costly), with average annual cost savings of USD −4336.65 (95% CI: −5207.89–−3903.32) and 8.11% higher rate of effectiveness (95% CI: −14.81–18.07) when compared with Rebif®. With regard to the use of MABs in comparison to Rebif®, MABs were associated with higher cost but a better rate of effectiveness, with an average additional annual cost of USD 1381.54 (95% CI: 421.31–3621.06) and 43.11% higher rate of effectiveness (95% CI: 30.38–61.15) when compared with Rebif®. In addition, the use of MABs was associated with higher cost but a better rate of effectiveness, with an average additional annual cost of USD 5717.88 (95% CI: 4970.75–8272.66) and 35% higher rate of effectiveness (95% CI: 10.0–42.50) when compared with orally administered agents. The use of MABs in the management of RRMS among the young patient population has shown to be the most effective therapy in comparison to both IFN-based therapy (e.g., Rebif®) and orally administered agents, but with higher cost. Orally administered agents resulted in better outcomes and lower costs in comparison to IFN-based therapy. Future studies should further examine the cost-effectiveness of different disease-modifying therapies for the management of RRMS using more robust study designs.
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Affiliation(s)
- Yazed AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh 11451, Saudi Arabia; (B.B.); (S.A.A.); (A.A.); (S.M.A.)
- Pharmacoeconomics Research Unit, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh 11451, Saudi Arabia
- Correspondence: ; Tel.: +966-114-677-483; Fax: +966-114-677-480
| | - Bander Balkhi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh 11451, Saudi Arabia; (B.B.); (S.A.A.); (A.A.); (S.M.A.)
- Pharmacoeconomics Research Unit, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh 11451, Saudi Arabia
| | - Sahar Abdullah Alkhalifah
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh 11451, Saudi Arabia; (B.B.); (S.A.A.); (A.A.); (S.M.A.)
| | - Salman Aljarallah
- Department of Medicine, Neurology Division, College of Medicine, King Saud University, P.O. Box 3145, Riyadh 12372, Saudi Arabia; (S.A.); (N.M.A.)
| | - Lama Almutairi
- Department of Pharmacy, King Khalid University Hospital, P.O. Box 3145, Riyadh 12372, Saudi Arabia; (L.A.); (M.A.)
| | - Miteb Alanazi
- Department of Pharmacy, King Khalid University Hospital, P.O. Box 3145, Riyadh 12372, Saudi Arabia; (L.A.); (M.A.)
| | - Abdulmalik Alajlan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh 11451, Saudi Arabia; (B.B.); (S.A.A.); (A.A.); (S.M.A.)
| | - Suliman M. Aldhafiri
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2454, Riyadh 11451, Saudi Arabia; (B.B.); (S.A.A.); (A.A.); (S.M.A.)
| | - Nuha M. Alkhawajah
- Department of Medicine, Neurology Division, College of Medicine, King Saud University, P.O. Box 3145, Riyadh 12372, Saudi Arabia; (S.A.); (N.M.A.)
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Lees S, Dicker M, Ku JE, Chaganti V, Mew-Sum M, Wang N, Smith A, Oldmeadow C, Goon WL, Bevan M, Lang D, Hinwood M. Impact of disease-modifying therapies on MRI and neurocognitive outcomes in relapsing-remitting multiple sclerosis: a protocol for a systematic review and network meta-analysis. BMJ Open 2021; 11:e051509. [PMID: 34728450 PMCID: PMC8565566 DOI: 10.1136/bmjopen-2021-051509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Disease-modifying therapies (DMTs) are the mainstay of treatment for relapsing-remitting multiple sclerosis (RRMS). There is established evidence that DMTs are effective at reducing relapse rate and disease progression in RRMS, but there has been less consideration to the synthesis of MRI and neurocognitive outcomes, which play an increasingly important role in treatment decisions. The aim of this systematic review and network meta-analysis is to examine the relative efficacy, acceptability and tolerability of DMTs for RRMS, using MRI and neurocognitive outcomes. METHODS AND ANALYSIS We will search electronic databases, including MEDLINE, Embase and the Cochrane Central Register of Controlled Trials, with no date restrictions. We will also search the websites of international regulatory bodies for pharmaceuticals and international trial registries. We will include parallel group randomised controlled trials of DMTs including interferon beta-1a intramuscular, interferon beta-1a subcutaneous, interferon beta-1b, peginterferon beta-1a, glatiramer acetate, natalizumab, ocrelizumab, alemtuzumab, dimethyl fumarate, teriflunomide, fingolimod, cladribine, ozanimod, mitoxantrone and rituximab, either head-to-head or against placebo in adults with RRMS. Primary outcomes include efficacy (MRI outcomes including new T1/hypointense lesions and T2/hyperintense lesions) and acceptability (all-cause dropouts). Secondary outcomes include gadolinium-enhancing lesions, cerebral atrophy and tolerability (dropouts due to adverse events). Neurocognitive measures across three domains including processing speed, working memory and verbal learning will be included as exploratory outcomes. Data will be analysed using a random-effects pairwise meta-analysis and a Bayesian hierarchical random effects network meta-analysis to evaluate the efficacy, acceptability and tolerability of the included DMTs. Subgroup and sensitivity analyses will be conducted to assess the robustness of the findings. The review will be reported using the Preferred Reporting Items for Systematic Reviews incorporating Network Meta-Analyses statement. ETHICS AND DISSEMINATION This protocol does not require ethics approval. Results will be disseminated in a peer-reviewed academic journal. PROSPERO REGISTRATION NUMBER CRD42021239630.
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Affiliation(s)
- Samuel Lees
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Mathew Dicker
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Jie En Ku
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Varun Chaganti
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Matthew Mew-Sum
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Nick Wang
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Angela Smith
- HNEHealth Libraries, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | | | - Wooi Lynn Goon
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Marc Bevan
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Danielle Lang
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Madeleine Hinwood
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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Lam KH, Twose J, McConchie H, Licitra G, Meijer K, de Ruiter L, van Lierop Z, Moraal B, Barkhof F, Uitdehaag B, de Groot V, Killestein J. Smartphone-derived keystroke dynamics are sensitive to relevant changes in multiple sclerosis. Eur J Neurol 2021; 29:522-534. [PMID: 34719076 PMCID: PMC9299491 DOI: 10.1111/ene.15162] [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: 09/25/2021] [Accepted: 10/24/2021] [Indexed: 12/03/2022]
Abstract
Background To investigate smartphone keystroke dynamics (KD), derived from regular typing, on sensitivity to relevant change in disease activity, fatigue, and clinical disability in multiple sclerosis (MS). Methods Preplanned interim analysis of a cohort study with 102 MS patients assessed at baseline and 3‐month follow‐up for gadolinium‐enhancing lesions on magnetic resonance imaging, relapses, fatigue and clinical disability outcomes. Keyboard interactions were unobtrusively collected during typing using the Neurokeys App. From these interactions 15 keystroke features were derived and aggregated using 16 summary and time series statistics. Responsiveness of KD to clinical anchor‐based change was assessed by calculating the area under the receiver operating characteristic curve (AUC). The optimal cut‐point was used to determine the minimal clinically important difference (MCID) and compared to the smallest real change (SRC). Commonly used clinical measures were analyzed for comparison. Results A total of 94 patients completed the follow‐up. The five best performing keystroke features had AUC‐values in the range 0.72–0.78 for change in gadolinium‐enhancing lesions, 0.67–0.70 for the Checklist Individual Strength Fatigue subscale, 0.66–0.79 for the Expanded Disability Status Scale, 0.69–0.73 for the Ambulation Functional System, and 0.72–0.75 for Arm function in MS Questionnaire. The MCID of these features exceeded the SRC on group level. KD had higher AUC‐values than comparative clinical measures for the study outcomes, aside from ambulatory function. Conclusions Keystroke dynamics demonstrated good responsiveness to changes in disease activity, fatigue, and clinical disability in MS, and detected important change beyond measurement error on group level. Responsiveness of KD was better than commonly used clinical measures.
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Affiliation(s)
- Ka-Hoo Lam
- Department of Neurology, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | | | | | - Kim Meijer
- Neurocast B.V., Amsterdam, The Netherlands
| | - Lodewijk de Ruiter
- Department of Neurology, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Zoë van Lierop
- Department of Neurology, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bastiaan Moraal
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Queen Square Institute of Neurology and Centre for Medical Image Computing, University College London, London, UK
| | - Bernard Uitdehaag
- Department of Neurology, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Vincent de Groot
- Department of Rehabilitation Medicine, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Joep Killestein
- Department of Neurology, MS Center Amsterdam, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Hunter SF, Bindra J, Chopra I, Niewoehner J, Panaccio MP, Wan GJ. Cost-Effectiveness of Repository Corticotropin Injection for the Treatment of Acute Exacerbations in Multiple Sclerosis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:883-892. [PMID: 34675568 PMCID: PMC8523315 DOI: 10.2147/ceor.s330118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background Relapses are common among patients with multiple sclerosis (MS) despite treatment with disease-modifying therapies. Repository corticotropin injection (RCI, Acthar® Gel), plasmapheresis (PMP), and intravenous immunoglobulin (IVIg) are alternative therapies for MS relapse. There is a dearth of economic assessments of these therapies for the acute exacerbations of MS. This study estimated the cost-effectiveness of RCI compared to PMP or IVIg. Methods A Markov state-transition model compared outcomes (costs, relapses, remission, and utilities) with RCI versus PMP or IVIg for the acute exacerbations in MS. The model was developed from the United States (US) payer and societal perspectives over one to three years. Patients initiated on alternative therapies were evaluated in one-day increments for the first 30 days during treatment. The model assumes the natural history of MS after treatment in the first month, adjusting for the effect of treatment. Incremental cost-effectiveness ratios (ICERs) were estimated as cost per quality-adjusted life-year (QALY) gained. The uncertainty in model parameters was evaluated in probabilistic sensitivity analyses. Results In the base case, RCI has an ICER of USD 42,078 per QALY compared to PMP over one year from the payer perspective and is dominant over two and three years; RCI is dominant compared to PMP from the societal perspective over all three years. Compared to IVIg, RCI is a dominant strategy from both payer and societal perspectives over all three years. Probabilistic sensitivity analysis supports the base case findings, suggesting that RCI may be cost-effective versus PMP and IVIg for acute exacerbations in MS. Conclusion RCI is a cost-effective alternative treatment for MS relapses compared to PMP and IVIg from the US payer and societal perspectives.
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Affiliation(s)
| | - Jas Bindra
- Falcon Research Group, North Potomac, MD, USA
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Dawoud D, Naci H, Ciani O, Bujkiewicz S. Raising the bar for using surrogate endpoints in drug regulation and health technology assessment. BMJ 2021; 374:n2191. [PMID: 34526320 DOI: 10.1136/bmj.n2191] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Dalia Dawoud
- Science, Evidence and Analytics Directorate, Science Policy and Research Programme, National Institute for Health and Care Excellence, London, UK
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, SDA Bocconi, Milan, Italy
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK
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Reich DS, Arnold DL, Vermersch P, Bar-Or A, Fox RJ, Matta A, Turner T, Wallström E, Zhang X, Mareš M, Khabirov FA, Traboulsee A. Safety and efficacy of tolebrutinib, an oral brain-penetrant BTK inhibitor, in relapsing multiple sclerosis: a phase 2b, randomised, double-blind, placebo-controlled trial. Lancet Neurol 2021; 20:729-738. [PMID: 34418400 PMCID: PMC8434816 DOI: 10.1016/s1474-4422(21)00237-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/21/2021] [Accepted: 07/07/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Tolebrutinib is an oral, CNS-penetrant, irreversible inhibitor of Bruton's tyrosine kinase, an enzyme expressed in B lymphocytes and myeloid cells including microglia, which are major drivers of inflammation in multiple sclerosis. We aimed to determine the dose-response relationship between tolebrutinib and the reduction in new active brain MRI lesions in patients with relapsing multiple sclerosis. METHODS We did a 16-week, phase 2b, randomised, double-blind, placebo-controlled, crossover, dose-finding trial at 40 centres (academic sites, specialty clinics, and general neurology centres) in ten countries in Europe and North America. Eligible participants were adults aged 18-55 years with diagnosed relapsing multiple sclerosis (either relapsing-remitting or relapsing secondary progressive multiple sclerosis), and one or more of the following criteria: at least one relapse within the previous year, at least two relapses within the previous 2 years, or at least one active gadolinium-enhancing brain lesion in the 6 months before screening. Exclusion criteria included a diagnosis of primary progressive multiple sclerosis or a diagnosis of secondary progressive multiple sclerosis without relapse. We used a two-step randomisation process to randomly assign eligible participants (1:1) to two cohorts, then further randomly assign participants in each cohort (1:1:1:1) to four tolebrutinib dose groups (5, 15, 30, and 60 mg administered once daily as an oral tablet). Cohort 1 received tolebrutinib for 12 weeks, then matched placebo (ie, identical looking tablets) for 4 weeks; cohort 2 received 4 weeks of placebo followed by 12 weeks of tolebrutinib. Participants and investigators were masked for dose and tolebrutinib-placebo administration sequence; investigators, study team members, and study participants did not have access to unmasked data. MRI scans were done at screening and every 4 weeks over 16 weeks. The primary efficacy endpoint was the number of new gadolinium-enhancing lesions detected on the scan done after 12 weeks of tolebrutinib treatment (assessed at week 12 for cohort 1 and week 16 for cohort 2), relative to the scan done 4 weeks previously, and compared with the lesions accumulated during 4 weeks of placebo run-in period in cohort 2. Efficacy data were analysed in a modified intention-to-treat population, using a two-step multiple comparison procedure with modelling analysis. Safety was assessed for all participants who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov (NCT03889639), EudraCT (2018-003927-12), and WHO (U1111-1220-0572), and has been completed. FINDINGS Between May 14, 2019, and Jan 2, 2020, we enrolled and randomly assigned 130 participants to tolebrutinib: 33 to 5 mg, 32 to 15 mg, 33 to 30 mg, and 32 to 60 mg. 129 (99%) completed the treatment regimen and 126 were included in the primary analysis. At treatment week 12, there was a dose-dependent reduction in the number of new gadolinium-enhancing lesions (mean [SD] lesions per patient: placebo, 1·03 [2·50]; 5 mg, 1·39 [3·20]; 15 mg, 0·77 [1·48]; 30 mg, 0·76 [3·31]; 60 mg, 0·13 [0·43]; p=0·03). One serious adverse event was reported (one patient in the 60 mg group was admitted to hospital because of a multiple sclerosis relapse). The most common non-serious adverse event during tolebrutinib treatment was headache (in one [3%] of 33 in the 5 mg group; three [9%] of 32 in the 15 mg group; one [3%] of 33 in the 30 mg group; and four [13%] of 32 in the 60 mg group). No safety-related discontinuations or treatment-related deaths occurred. INTERPRETATION 12 weeks of tolebrutinib treatment led to a dose-dependent reduction in new gadolinium-enhancing lesions, the 60 mg dose being the most efficacious, and the drug was well tolerated. Reduction of acute inflammation, combined with the potential to modulate the immune response within the CNS, provides a scientific rationale to pursue phase 3 clinical trials of tolebrutinib in patients with relapsing and progressive forms of multiple sclerosis. FUNDING Sanofi.
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Affiliation(s)
- Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA.
| | - Douglas L Arnold
- NeuroRx Research and Montréal Neurological Institute, McGill University, Montréal, QC, Canada
| | - Patrick Vermersch
- Lille Neuroscience et Cognition, University Lille, INSERM UMR-S1172, CHU Lille, FHU Imminent, Lille, France
| | - Amit Bar-Or
- Center for Neuroinflammation and Neurotherapeutics and the Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert J Fox
- MellenCenter for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | | - Miroslav Mareš
- Department of Neurology, Pardubice Regional Hospital, Pardubice, Czech Republic
| | | | - Anthony Traboulsee
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Healy BC, Glanz BI, Swallow E, Signorovitch J, Hagan K, Silva D, Pelletier C, Chitnis T, Weiner H. Confirmed disability progression provides limited predictive information regarding future disease progression in multiple sclerosis. Mult Scler J Exp Transl Clin 2021; 7:2055217321999070. [PMID: 33953937 PMCID: PMC8042549 DOI: 10.1177/2055217321999070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background Although confirmed disability progression (CDP) is a common outcome in multiple sclerosis (MS) clinical trials, its predictive value for long-term outcomes is uncertain. Objective To investigate whether CDP at month 24 predicts subsequent disability accumulation in MS. Methods The Comprehensive Longitudinal Investigation of Multiple Sclerosis at Brigham and Women's Hospital includes participants with relapsing-remitting MS or clinically isolated syndrome with Expanded Disability Status Scale (EDSS) scores ≤5 (N = 1214). CDP was assessed as a predictor of time to EDSS score 6 (EDSS 6) and to secondary progressive MS (SPMS) using a Cox proportional hazards model; adjusted models included additional clinical/participant characteristics. Models were compared using Akaike's An Information Criterion. Results CDP was directionally associated with faster time to EDSS 6 in univariate analysis (HR = 1.61 [95% CI: 0.83, 3.13]). After adjusting for month 24 EDSS, CDP was directionally associated with slower time to EDSS 6 (adjusted HR = 0.65 [0.32, 1.28]). Models including CDP had worse fit statistics than those using EDSS scores without CDP. When models included clinical and magnetic resonance imaging measures, T2 lesion volume improved fit statistics. Results were similar for time to SPMS. Conclusions CDP was less predictive of time to subsequent events than other MS clinical features.
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Schwarz AJ. The Use, Standardization, and Interpretation of Brain Imaging Data in Clinical Trials of Neurodegenerative Disorders. Neurotherapeutics 2021; 18:686-708. [PMID: 33846962 PMCID: PMC8423963 DOI: 10.1007/s13311-021-01027-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 12/11/2022] Open
Abstract
Imaging biomarkers play a wide-ranging role in clinical trials for neurological disorders. This includes selecting the appropriate trial participants, establishing target engagement and mechanism-related pharmacodynamic effect, monitoring safety, and providing evidence of disease modification. In the early stages of clinical drug development, evidence of target engagement and/or downstream pharmacodynamic effect-especially with a clear relationship to dose-can provide confidence that the therapeutic candidate should be advanced to larger and more expensive trials, and can inform the selection of the dose(s) to be further tested, i.e., to "de-risk" the drug development program. In these later-phase trials, evidence that the therapeutic candidate is altering disease-related biomarkers can provide important evidence that the clinical benefit of the compound (if observed) is grounded in meaningful biological changes. The interpretation of disease-related imaging markers, and comparability across different trials and imaging tools, is greatly improved when standardized outcome measures are defined. This standardization should not impinge on scientific advances in the imaging tools per se but provides a common language in which the results generated by these tools are expressed. PET markers of pathological protein aggregates and structural imaging of brain atrophy are common disease-related elements across many neurological disorders. However, PET tracers for pathologies beyond amyloid β and tau are needed, and the interpretability of structural imaging can be enhanced by some simple considerations to guard against the possible confound of pseudo-atrophy. Learnings from much-studied conditions such as Alzheimer's disease and multiple sclerosis will be beneficial as the field embraces rarer diseases.
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Affiliation(s)
- Adam J Schwarz
- Takeda Pharmaceuticals Ltd., 40 Landsdowne Street, Cambridge, MA, 02139, USA.
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Abstract
PURPOSE OF REVIEW Multiple sclerosis (MS) is a clinically heterogeneous disease, which complicates expectant management as well as treatment decisions. This review provides an overview of both well established and emerging predictors of disability worsening, including clinical factors, imaging factors, biomarkers and treatment strategies. RECENT FINDINGS In addition to well known clinical predictors (age, male sex, clinical presentation, relapse behaviour), smoking, obesity, vascular and psychiatric comorbidities are associated with subsequent disability worsening in persons with MS. A number of imaging features are predictive of disability worsening and are present to varying degrees in relapsing and progressive forms of MS. These include brain volumes, spinal cord atrophy, lesion volumes and optical coherence tomography features. Cerebrospinal and more recently blood biomarkers including neurofilament light show promise as more easily attainable biomarkers of future disability accumulation. Importantly, recent observational studies suggest that initiation of early-intensive therapy, as opposed to escalation based on breakthrough disease, is associated with decreased accumulation of disability overall, although randomized controlled trials investigating this question are underway. SUMMARY Understanding risk factors associated with disability progression can help to both counsel patients and enhance the clinician's availability to provide evidence-based treatment recommendations.
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Haas J, Jeffery D, Silva D, Meier DP, Meinert R, Cohen J, Hartung HP. Early initiation of fingolimod reduces the rate of severe relapses over the long term: Post hoc analysis from the FREEDOMS, FREEDOMS II, and TRANSFORMS studies. Mult Scler Relat Disord 2019; 36:101335. [PMID: 31557679 DOI: 10.1016/j.msard.2019.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/21/2019] [Accepted: 07/19/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Relapse frequency is often correlated with the prognosis of multiple sclerosis (MS). In patients with relapsing-remitting MS (RRMS), relapses vary in severity and may affect activities of daily living, require steroid intervention, or hospitalization. Incomplete recovery from relapses results in increasing disability. In pivotal phase III studies of fingolimod (FREEDOMS, FREEDOMS II, and TRANSFORMS), the frequency of overall and severe relapses was significantly reduced in patients with RRMS treated with fingolimod compared with placebo or intramuscular interferon β-1a (IFN β-1a). The objective of this study was to report the effect of early initiation of fingolimod on relapse severity in patients with RRMS. METHODS This is a post hoc descriptive analysis of data from the pooled placebo-controlled FREEDOMS/FREEDOMS II studies and from the active-comparator TRANSFORMS study. Patients were analyzed under 2 groups: patients initially randomized to receive fingolimod 0.5 mg during the core phase and continued fingolimod 0.5 mg in the extension phase (immediate fingolimod group), and patients initially randomized to placebo or IFN β-1a during the core phase and switched to fingolimod during the extension phase (delayed fingolimod group). Annualized relapse rate (ARR) was estimated for severe relapses (defined as Expanded Disability Status Scale increase of >1 point, or >2-point change in 1 or 2 Functional Systems, respectively, or >1-point change in >4 Functional Systems). ARR was also estimated for relapses that affected activities of daily living, required steroid use, or hospitalization. RESULTS In the pooled FREEDOMS/FREEDOMS II extensions, the immediate fingolimod group showed sustained reductions in the proportion (core: 15.8% and extension: 9.3%) and in ARR over 4 years (0.032 and 0.015) for severe relapses, in relapses requiring steroids (0.149 and 0.123), hospitalization (0.049 and 0.039) and relapses affecting activities of daily living (0.155 and 0.112). In the TRANSFORMS extension, similar reductions were observed in the immedaite group for the proportion of severe relapses (core: 11.8% and extension: 9.8%). ARR remained low over 2 years for severe relapses (0.024 and 0.018), relapses affecting activities of daily living (0.112 and 0.109), relapses requiring steroids (0.156 and 0.161) and hospitalization (0.027 and 0.033). Results in the FREEDOMS/FREEDOMS II and TRANSFORMS extensions for the delayed group were similar. In the TRANSFORMS extension, the proportion of severe relapses were 18.0% (core) and 11.1% (extension); there were significant reductions in ARR for severe relapses (core: 0.079 and extension: 0.029), relapses requiring steroids (0.366 and 0.232), hospitalization (0.092 and 0.055), and relapses affecting activities of daily living (0.285 and 0.144) (all p < 0.0001). Complete recovery was reported for the majority of relapses during the core and extension phases in both the immediate and delayed fingolimod groups (Pooled FREEDOMS/FREEDOMS II: immediate group 59.7%-65.5% and delayed group 64.9%-67.7%; TRANSFORMS: 72.1%-80.0% and 65.4%-70.8%). CONCLUSIONS In patients with RRMS, the frequency of severe relapses and relapse severity remained low in the immedaite fingolimod group over a period of 4 years. Reductions in the proportion of severe relapses post switch from IFN β-1a or placebo to fingolimod underscore the clinical benefit and the relevance of an early initiation of fingolimod.
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Affiliation(s)
- Judith Haas
- Center for Multiple Sclerosis, Jewish Hospital, Berlin, Germany.
| | | | | | | | | | - Jeffrey Cohen
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
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Saint-Hilary G, Barboux V, Pannaux M, Gasparini M, Robert V, Mastrantonio G. Predictive probability of success using surrogate endpoints. Stat Med 2018; 38:1753-1774. [PMID: 30548627 DOI: 10.1002/sim.8060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 10/29/2018] [Accepted: 11/19/2018] [Indexed: 12/30/2022]
Abstract
The predictive probability of success of a future clinical trial is a key quantitative tool for decision-making in drug development. It is derived from prior knowledge and available evidence, and the latter typically comes from the accumulated data on the clinical endpoint of interest in previous clinical trials. However, a surrogate endpoint could be used as primary endpoint in early development and, usually, no or limited data are collected on the clinical endpoint of interest. We propose a general, reliable, and broadly applicable methodology to predict the success of a future trial from surrogate endpoints, in a way that makes the best use of all the available evidence. The predictions are based on an informative prior, called surrogate prior, derived from the results of past trials on one or several surrogate endpoints. If available, in a Bayesian framework, this prior could be combined with data from past trials on the clinical endpoint of interest. Two methods are proposed to address a potential discordance between the surrogate prior and the data on the clinical endpoint. We investigate the patterns of behavior of the predictions in a comprehensive simulation study, and we present an application to the development of a drug in Multiple Sclerosis. The proposed methodology is expected to support decision-making in many different situations, since the use of predictive markers is important to accelerate drug developments and to select promising drug candidates, better and earlier.
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Affiliation(s)
- Gaelle Saint-Hilary
- Dipartimento di Scienze Matematiche (DISMA) Giuseppe Luigi Lagrange, Politecnico di Torino, Turin, Italy
| | - Valentine Barboux
- Department of Biostatistics, Institut de Recherches Internationales Servier (IRIS), Suresnes, France
| | - Matthieu Pannaux
- Department of Biostatistics, Institut de Recherches Internationales Servier (IRIS), Suresnes, France
| | - Mauro Gasparini
- Dipartimento di Scienze Matematiche (DISMA) Giuseppe Luigi Lagrange, Politecnico di Torino, Turin, Italy
| | - Veronique Robert
- Department of Biostatistics, Institut de Recherches Internationales Servier (IRIS), Suresnes, France
| | - Gianluca Mastrantonio
- Dipartimento di Scienze Matematiche (DISMA) Giuseppe Luigi Lagrange, Politecnico di Torino, Turin, Italy
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16
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Zimmermann M, Brouwer E, Tice JA, Seidner M, Loos AM, Liu S, Chapman RH, Kumar V, Carlson JJ. Disease-Modifying Therapies for Relapsing-Remitting and Primary Progressive Multiple Sclerosis: A Cost-Utility Analysis. CNS Drugs 2018; 32:1145-1157. [PMID: 30141001 DOI: 10.1007/s40263-018-0566-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several disease-modifying therapies (DMTs) treat relapsing-remitting multiple sclerosis (RRMS) and primary progressive multiple sclerosis (PPMS). Few comprehensive cost-effectiveness analyses exist in this area, particularly from a payer perspective, despite rapidly increasing prices of DMTs. OBJECTIVE We aimed to systematically compare cost effectiveness of all relevant DMTs for first-line treatment of RRMS, second-line treatment of RRMS, and first-line treatment of PPMS. METHODS We used a Markov model with health states based on Expanded Disability Status Score categories. Upon discontinuing first-line treatment, RRMS patients continued to second-line therapy then to supportive care, and PPMS patients moved directly to supportive care. Data was sourced from clinical trials and commercially and publicly available sources. The target population was treatment-naïve adults with RRMS or PPMS. We used a lifetime horizon from a US payer perspective, and compared DMTs for RRMS (first-line: dimethyl fumarate, glatiramer acetate, interferon β-1a, interferon β-1b, peginterferon β-1a, teriflunomide, natalizumab, fingolimod, and ocrelizumab; second-line: alemtuzumab, natalizumab, fingolimod, and ocrelizumab), ocrelizumab for PPMS, and supportive care. Outcome measures included total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS For RRMS first-line therapy, ocrelizumab dominated the other DMTs with an ICER of US$166,338/QALY compared with supportive care. For RRMS second-line therapy, alemtuzumab dominated the other three DMTs, providing more QALYs for lower costs. For PPMS, ocrelizumab had an ICER of US$648,799/QALY compared with supportive care. Wide variability in results was observed in the probabilistic sensitivity analysis. Results were sensitive to the relative risk of progression and cost of DMTs. CONCLUSIONS Ocrelizumab would likely be cost effective as a first-line treatment for RRMS with a discounted price but was not cost effective for PPMS. Alemtuzumab dominated other options for second-line treatment of RRMS. Other DMTs were generally similar in terms of costs and health outcomes, providing health benefits compared to supportive care but with significant added costs. If drug prices were lowered, more DMTs could be cost effective.
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Affiliation(s)
| | | | - Jeffrey A Tice
- University of California, San Francisco, San Francisco, CA, USA
| | - Matt Seidner
- Institute for Clinical and Economic Review, Boston, MA, USA
| | - Anne M Loos
- Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, MA, USA
| | | | | | - Varun Kumar
- Institute for Clinical and Economic Review, Boston, MA, USA
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17
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Comi G, Nicoletti F, Canonico PL, Centonze D. Letter to the Editor Regarding: A Comprehensive Review on Copemyl ®. Neurol Ther 2018; 7:385-390. [PMID: 30415356 PMCID: PMC6283790 DOI: 10.1007/s40120-018-0115-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Indexed: 11/23/2022] Open
Affiliation(s)
- Giancarlo Comi
- Department of Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Ferdinando Nicoletti
- Department of Physiology and Pharmacology, University of Rome "La Sapienza", Rome, Italy
- IRCCS Neuromed, Pozzilli, IS, Italy
| | - Pier Luigi Canonico
- DISCAFF Department, University of Piemonte Orientale "Amedeo Avogadro", Novara, Italy
| | - Diego Centonze
- Neurology and Neurorehabilitation Units, IRCCS Neuromed, Pozzilli, IS, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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18
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Freedman MS, Leist TP, Comi G, Cree BA, Coyle PK, Hartung HP, Vermersch P, Damian D, Dangond F. The efficacy of cladribine tablets in CIS patients retrospectively assigned the diagnosis of MS using modern criteria: Results from the ORACLE-MS study. Mult Scler J Exp Transl Clin 2017; 3:2055217317732802. [PMID: 29051829 PMCID: PMC5637982 DOI: 10.1177/2055217317732802] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 08/07/2017] [Indexed: 11/15/2022] Open
Abstract
Background Multiple sclerosis (MS) diagnostic criteria have changed since the ORACLE-MS study was conducted; 223 of 616 patients (36.2%) would have met the diagnosis of MS vs clinically isolated syndrome (CIS) using the newer criteria. Objective The objective of this paper is to assess the effect of cladribine tablets in patients with a first clinical demyelinating attack fulfilling newer criteria (McDonald 2010) for MS vs CIS. Methods A post hoc analysis for subgroups of patients retrospectively classified as fulfilling or not fulfilling newer criteria at the first clinical demyelinating attack was conducted. Results Cladribine tablets 3.5 mg/kg (n = 68) reduced the risk of next attack or three-month confirmed Expanded Disability Status Scale (EDSS) worsening by 74% vs placebo (n = 72); p = 0.0009 in patients meeting newer criteria for MS at baseline. Cladribine tablets 5.25 mg/kg (n = 83) reduced the risk of next attack or three-month confirmed EDSS worsening by 37%, but nominal significance was not reached (p = 0.14). In patients who were still CIS after applying newer criteria, cladribine tablets 3.5 mg/kg (n = 138) reduced the risk of conversion to clinically definite multiple sclerosis (CDMS) by 63% vs placebo (n = 134); p = 0.0003. Cladribine tablets 5.25 mg/kg (n = 121) reduced the risk of conversion by 75% vs placebo (n = 134); p < 0.0001. Conclusions Regardless of the criteria used to define CIS or MS, 3.5 mg/kg cladribine tablets are effective in patients with a first clinical demyelinating attack. ClinicalTrials.gov registration: The ORACLE-MS study (NCT00725985).
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Affiliation(s)
- Mark S Freedman
- Department of Medicine (Neurology), University of Ottawa and the Ottawa Hospital Research Institute, Canada
| | - Thomas P Leist
- Division of Clinical Neuroimmunology, Thomas Jefferson University, USA
| | - Giancarlo Comi
- Department of Neurology and Institute of Experimental Neurology, Università Vita-Salute San Raffaele, Ospedale San Raffaele, Italy
| | | | | | - Hans-Peter Hartung
- Department of Neurology, Heinrich Heine University, Medical Faculty, Germany
| | - Patrick Vermersch
- University of Lille, CHU Lille, LIRIC-INSERM U995, FHU Imminent, France
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Jackson D, Bujkiewicz S, Law M, Riley RD, White IR. A matrix-based method of moments for fitting multivariate network meta-analysis models with multiple outcomes and random inconsistency effects. Biometrics 2017; 74:548-556. [PMID: 28806485 DOI: 10.1111/biom.12762] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 06/01/2017] [Accepted: 06/01/2017] [Indexed: 01/11/2023]
Abstract
Random-effects meta-analyses are very commonly used in medical statistics. Recent methodological developments include multivariate (multiple outcomes) and network (multiple treatments) meta-analysis. Here, we provide a new model and corresponding estimation procedure for multivariate network meta-analysis, so that multiple outcomes and treatments can be included in a single analysis. Our new multivariate model is a direct extension of a univariate model for network meta-analysis that has recently been proposed. We allow two types of unknown variance parameters in our model, which represent between-study heterogeneity and inconsistency. Inconsistency arises when different forms of direct and indirect evidence are not in agreement, even having taken between-study heterogeneity into account. However, the consistency assumption is often assumed in practice and so we also explain how to fit a reduced model which makes this assumption. Our estimation method extends several other commonly used methods for meta-analysis, including the method proposed by DerSimonian and Laird (). We investigate the use of our proposed methods in the context of both a simulation study and a real example.
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Affiliation(s)
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, U.K
| | | | - Richard D Riley
- Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, University of Keele, U.K
| | - Ian R White
- MRC Biostatistics Unit, Cambridge, U.K.,MRC Clinical Trials Unit at University College London, U.K
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20
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Colais P, Agabiti N, Davoli M, Buttari F, Centonze D, De Fino C, Di Folco M, Filippini G, Francia A, Galgani S, Gasperini C, Giuliani M, Mirabella M, Nociti V, Pozzilli C, Bargagli A. Identifying Relapses in Multiple Sclerosis Patients through Administrative Data: A Validation Study in the Lazio Region, Italy. Neuroepidemiology 2017; 48:171-178. [PMID: 28793295 DOI: 10.1159/000479515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 07/11/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Relapse is frequently considered an outcome measure of disease activity in relapsing-remitting multiple sclerosis (MS). The objectives of this study were to identify relapse episodes in patients with MS in the Lazio region using health administrative databases and to evaluate the validity of the algorithm using patients enrolled at MS treatment centers. METHODS MS cases were identified in the period between January 1, 2006 and December 31, 2009 using data from regional Health Information Systems (HIS). An algorithm based on HIS was used to identify relapse episodes, and patients recruited at MS centers were used to validate the algorithm. Positive and negative predictive values (PPV, NPV) and the Cohen's kappa coefficient were calculated. RESULTS The overall MS population identified through HIS consisted of 6,094 patients, of whom 67.1% were female and the mean age was 41.5. Among the MS patients identified by the algorithm, 2,242 attended the centers and 3,852 did not. The PPV was 58.9%, the NPV was 76.3%, and the kappa was 0.36. CONCLUSIONS The proposed algorithm based on health administrative databases does not seem to be able to reliably detect relapses; however, it may be a helpful tool to detect healthcare utilization, and therefore to identify the worsening condition of a patient's health.
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Affiliation(s)
- Paola Colais
- Department of Epidemiology, Regional Health Service, Lazio Region, Rome, Italy
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21
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Hu X, Hang Y, Cui Y, Zhang J, Liu S, Seddighzadeh A, Deykin A, Nestorov I. Population-Based Pharmacokinetic and Exposure-Efficacy Analyses of Peginterferon Beta-1a in Patients With Relapsing Multiple Sclerosis. J Clin Pharmacol 2017; 57:1005-1016. [PMID: 28394418 PMCID: PMC5516189 DOI: 10.1002/jcph.883] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/20/2017] [Indexed: 11/24/2022]
Abstract
Peginterferon beta‐1a reduced annualized relapse rate as compared with placebo and was approved to treat multiple sclerosis patients. A population pharmacokinetic and an exposure‐efficacy model were developed to establish the quantitative relationship between pharmacokinetics and annualized relapse rate. The pharmacokinetics was well described by a 1‐compartment model with first‐order absorption and linear elimination kinetics. Body mass index was the most significant covariate that impacted both clearance and volume of distribution, which in turn impacted area under the curve and maximum serum concentration. Cumulative monthly area under the curve and annualized relapse rate were best described by a Poisson‐gamma (negative binomial) model, demonstrating that the improved efficacy of every‐2‐weeks dosing was driven by greater drug exposure. The results supported the superior efficacy of the every‐2‐week dosing regimen compared with the every‐4‐weeks dosing regimen.
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Affiliation(s)
| | | | | | - Jie Zhang
- Gilead Sciences Inc, Cambridge, MA, USA
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22
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Andermatt S, Papadopoulou A, Radue EW, Sprenger T, Cattin P. Tracking the Evolution of Cerebral Gadolinium-Enhancing Lesions to Persistent T1 Black Holes in Multiple Sclerosis: Validation of a Semiautomated Pipeline. J Neuroimaging 2017; 27:469-475. [PMID: 28370651 DOI: 10.1111/jon.12439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 02/27/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Some gadolinium-enhancing multiple sclerosis (MS) lesions remain T1-hypointense over months ("persistent black holes, BHs") and represent areas of pronounced tissue loss. A reduced conversion of enhancing lesions to persistent BHs could suggest a favorable effect of a medication on tissue repair. However, the individual tracking of enhancing lesions can be very time-consuming in large clinical trials. PURPOSE We created a semiautomated workflow for tracking the evolution of individual MS lesions, to calculate the proportion of enhancing lesions becoming persistent BHs at follow-up. METHODS Our workflow automatically coregisters, compares, and detects overlaps between lesion masks at different time points. We tested the algorithm in a data set of Magnetic Resonance images (1.5 and 3T; spin-echo T1-sequences) from a phase 3 clinical trial (n = 1,272), in which all enhancing lesions and all BHs had been previously segmented at baseline and year 2. The algorithm analyzed the segmentation masks in a longitudinal fashion to determine which enhancing lesions at baseline turned into BHs at year 2. Images of 50 patients (192 enhancing lesions) were also reviewed by an experienced MRI rater, blinded to the algorithm results. RESULTS In this MRI data set, there were no cases that could not be processed by the algorithm. At year 2, 417 lesions were classified as persistent BHs (417/1,613 = 25.9%). The agreement between the rater and the algorithm was > 98%. CONCLUSIONS Due to the semiautomated procedure, this algorithm can be of great value in the analysis of large clinical trials, when a rater-based analysis would be time-consuming.
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Affiliation(s)
- Simon Andermatt
- Department of Biomedical Engineering, University of Basel, Basel, CH
| | - Athina Papadopoulou
- Neurology Clinic and Policlinic, University Hospital Basel and University of Basel, Basel, CH.,Medical Image Analysis Center, Basel, CH
| | | | - Till Sprenger
- Neurology Clinic and Policlinic, University Hospital Basel and University of Basel, Basel, CH.,Medical Image Analysis Center, Basel, CH.,Department of Neurology, DKD HELIOS Klinik Wiesbaden, Wiesbaden, Germany
| | - Philippe Cattin
- Department of Biomedical Engineering, University of Basel, Basel, CH
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Nash RA, Hutton GJ, Racke MK, Popat U, Devine SM, Steinmiller KC, Griffith LM, Muraro PA, Openshaw H, Sayre PH, Stuve O, Arnold DL, Wener MH, Georges GE, Wundes A, Kraft GH, Bowen JD. High-dose immunosuppressive therapy and autologous HCT for relapsing-remitting MS. Neurology 2017; 88:842-852. [PMID: 28148635 PMCID: PMC5331868 DOI: 10.1212/wnl.0000000000003660] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 12/09/2016] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To evaluate the safety, efficacy, and durability of multiple sclerosis (MS) disease stabilization after high-dose immunosuppressive therapy (HDIT) and autologous hematopoietic cell transplantation (HCT). METHODS High-Dose Immunosuppression and Autologous Transplantation for Multiple Sclerosis (HALT-MS) is a phase II clinical trial of HDIT/HCT for patients with relapsing-remitting (RR) MS who experienced relapses with disability progression (Expanded Disability Status Scale [EDSS] 3.0-5.5) while on MS disease-modifying therapy. The primary endpoint was event-free survival (EFS), defined as survival without death or disease activity from any one of: disability progression, relapse, or new lesions on MRI. Participants were evaluated through 5 years posttransplant. Toxicities were reported using the National Cancer Institute Common Terminology Criteria for Adverse Events (AE). RESULTS Twenty-five participants were evaluated for transplant and 24 participants underwent HDIT/HCT. Median follow-up was 62 months (range 12-72). EFS was 69.2% (90% confidence interval [CI] 50.2-82.1). Progression-free survival, clinical relapse-free survival, and MRI activity-free survival were 91.3% (90% CI 74.7%-97.2%), 86.9% (90% CI 69.5%-94.7%), and 86.3% (90% CI 68.1%-94.5%), respectively. AE due to HDIT/HCT were consistent with expected toxicities and there were no significant late neurologic adverse effects noted. Improvements were noted in neurologic disability with a median change in EDSS of -0.5 (interquartile range -1.5 to 0.0; p = 0.001) among participants who survived and completed the study. CONCLUSION HDIT/HCT without maintenance therapy was effective for inducing long-term sustained remissions of active RRMS at 5 years. CLINICALTRIALSGOV IDENTIFIER NCT00288626. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that participants with RRMS experienced sustained remissions with toxicities as expected from HDIT/HCT.
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Affiliation(s)
- Richard A Nash
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA.
| | - George J Hutton
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Michael K Racke
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Uday Popat
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Steven M Devine
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Kaitlyn C Steinmiller
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Linda M Griffith
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Paolo A Muraro
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Harry Openshaw
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Peter H Sayre
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Olaf Stuve
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Douglas L Arnold
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Mark H Wener
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - George E Georges
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - Annette Wundes
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - George H Kraft
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
| | - James D Bowen
- From the Colorado Blood Cancer Institute (R.A.N.), Denver; Baylor College of Medicine (G.J.H.), Houston, TX; Ohio State University (M.K.R., S.M.D.), Columbus; MD Anderson Cancer Research Center (U.P.), Houston, TX; Rho, Inc. (K.C.S.), Chapel Hill, NC; National Institute of Allergy and Infectious Diseases (L.M.G.), National Institutes of Health, Bethesda, MD; Division of Brain Sciences (P.A.M.), Imperial College London, UK; City of Hope National Medical Center (H.O.), Duarte, CA; Immune Tolerance Network (P.H.S.), University of California San Francisco; University of Texas Southwestern (O.S.), Dallas; NeuroRx (D.L.A.), McGill University, Montreal, Canada; Fred Hutchinson Cancer Research Center (G.E.G.), University of Washington (M.H.W., A.W., G.H.K.); and Swedish Hospital Medical Center (J.D.B.), Seattle, WA
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Raffel J, Gafson AR, Dahdaleh S, Malik O, Jones B, Nicholas R. Inflammatory Activity on Natalizumab Predicts Short-Term but Not Long-Term Disability in Multiple Sclerosis. PLoS One 2017; 12:e0169546. [PMID: 28081190 PMCID: PMC5231343 DOI: 10.1371/journal.pone.0169546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 12/19/2016] [Indexed: 11/19/2022] Open
Abstract
Background In people with multiple sclerosis treated with interferon-beta or glatiramer acetate, new MRI lesions and relapses during the first year of treatment predict a poor prognosis. Objective To study this association in those receiving natalizumab. Methods Data were collected on relapses, new MRI activity, and Modified Rio Score after initiation of natalizumab in an observational cohort of 161 patients with high baseline disability. These were correlated with Expanded Disability Status Scale (EDSS) progression at years 1, 2, 3, and 3–7 after treatment initiation, versus pre-treatment baseline. Results 46/161 patients had a relapse in the first year and 44/161 had EDSS progression by year 2. Relapses and Modified Rio Score in the first year of treatment predicted EDSS progression at year 1 and 2 after treatment initiation. However, this effect disappeared with longer follow-up. Paradoxically, there was a trend towards inflammatory activity on treatment (first year Modified Rio Score, relapses, and MRI activity) predicting a lower risk of EDSS progression by years 3–7, although this did not reach statistical significance. Those with and without EDSS progression did not differ in baseline age, EDSS, or pre-treatment relapse rate. Relapses in year 0–1 predicted further relapses in years 1–3. Conclusions Breakthrough inflammatory activity after natalizumab treatment is predictive of short-term outcome measures of relapses or EDSS progression, but does not predict longer term EDSS progression, in this cohort with high baseline disability.
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Affiliation(s)
- Joel Raffel
- Department of Medicine, Imperial College London, London, United Kingdom
- * E-mail:
| | - Arie R. Gafson
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Samer Dahdaleh
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Omar Malik
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Brynmor Jones
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Richard Nicholas
- Department of Medicine, Imperial College London, London, United Kingdom
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Dulamea AO. Role of Oligodendrocyte Dysfunction in Demyelination, Remyelination and Neurodegeneration in Multiple Sclerosis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 958:91-127. [PMID: 28093710 DOI: 10.1007/978-3-319-47861-6_7] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Oligodendrocytes (OLs) are the myelinating cells of the central nervous system (CNS) during development and throughout adulthood. They result from a complex and well controlled process of activation, proliferation, migration and differentiation of oligodendrocyte progenitor cells (OPCs) from the germinative niches of the CNS. In multiple sclerosis (MS), the complex pathological process produces dysfunction and apoptosis of OLs leading to demyelination and neurodegeneration. This review attempts to describe the patterns of demyelination in MS, the steps involved in oligodendrogenesis and myelination in healthy CNS, the different pathways leading to OLs and myelin loss in MS, as well as principles involved in restoration of myelin sheaths. Environmental factors and their impact on OLs and pathological mechanisms of MS are also discussed. Finally, we will present evidence about the potential therapeutic targets in re-myelination processes that can be accessed in order to develop regenerative therapies for MS.
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Affiliation(s)
- Adriana Octaviana Dulamea
- Neurology Clinic, University of Medicine and Pharmacy "Carol Davila", Fundeni Clinical Institute, Building A, Neurology Clinic, Room 201, 022328, Bucharest, Romania.
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Abstract
Due to the heterogeneous nature of the disease, it is a challenge to capture disease activity of multiple sclerosis (MS) in a reliable and valid way. Therefore, it can be difficult to assess the true efficacy of interventions in clinical trials. In phase III trials in MS, the traditionally used primary clinical outcome measures are the Expanded Disability Status Scale and the relapse rate. Secondary outcome measures in these trials are the number or volume of T2 hyperintense lesions and gadolinium-enhancing T1 lesions on magnetic resonance imaging (MRI) of the brain. These secondary outcome measures are often primary outcome measures in phase II trials in MS. Despite several limitations, the traditional clinical measures are still the mainstay for assessing treatment efficacy. Newer and potentially valuable outcome measures increasingly used or explored in MS trials are, clinically, the MS Functional Composite and patient-reported outcome measures, and on MRI, brain atrophy and the formation of persisting black holes. Several limitations of these measures have been addressed and further improvements will probably be proposed. Major improvements are the coverage of additional functional domains such as cognitive functioning and assessment of the ability to carry out activities of daily living. The development of multidimensional measures is promising because these measures have the potential to cover the full extent of MS activity and progression. In this review, we provide an overview of the historical background and recent developments of outcome measures in MS trials. We discuss the advantages and limitations of various measures, including newer assessments such as optical coherence tomography, biomarkers in body fluids and the concept of 'no evidence of disease activity'.
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Affiliation(s)
- Caspar E. P. van Munster
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, De Boelelaan 1117, 1081 Amsterdam, The Netherlands
| | - Bernard M. J. Uitdehaag
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, De Boelelaan 1117, 1081 Amsterdam, The Netherlands
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Arnold DL, Fisher E, Brinar VV, Cohen JA, Coles AJ, Giovannoni G, Hartung HP, Havrdova E, Selmaj KW, Stojanovic M, Weiner HL, Lake SL, Margolin DH, Thomas DR, Panzara MA, Compston DAS. Superior MRI outcomes with alemtuzumab compared with subcutaneous interferon β-1a in MS. Neurology 2016; 87:1464-1472. [PMID: 27590291 PMCID: PMC5075976 DOI: 10.1212/wnl.0000000000003169] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 06/16/2016] [Indexed: 12/18/2022] Open
Abstract
Objective: To describe detailed MRI results from 2 head-to-head phase III trials, Comparison of Alemtuzumab and Rebif Efficacy in Multiple Sclerosis Study I (CARE-MS I; NCT00530348) and Study II (CARE-MS II; NCT00548405), of alemtuzumab vs subcutaneous interferon β-1a (SC IFN-β-1a) in patients with active relapsing-remitting multiple sclerosis (RRMS). Methods: The impact of alemtuzumab 12 mg vs SC IFN-β-1a 44 μg on MRI measures was evaluated in patients with RRMS who were treatment-naive (CARE-MS I) or who had an inadequate response, defined as at least one relapse, to prior therapy (CARE-MS II). Results: Both treatments prevented T2-hyperintense lesion volume increases from baseline. Alemtuzumab was more effective than SC IFN-β-1a on most lesion-based endpoints in both studies (p < 0.05), including decreased risk of new/enlarging T2 lesions over 2 years and gadolinium-enhancing lesions at year 2. Reduced risk of new T1 lesions (p < 0.0001) and gadolinium-enhancing lesion conversion to T1-hypointense black holes (p = 0.0078) were observed with alemtuzumab vs SC IFN-β-1a in CARE-MS II. Alemtuzumab slowed brain volume loss over 2 years in CARE-MS I (p < 0.0001) and II (p = 0.012) vs SC IFN-β-1a. Conclusions: Alemtuzumab demonstrated greater efficacy than SC IFN-β-1a on MRI endpoints in active RRMS. The superiority of alemtuzumab was more prominent during the second year of both studies. These findings complement the superior clinical efficacy of alemtuzumab over SC IFN-β-1a in RRMS. ClinicalTrials.gov identifier: NCT00530348 and NCT00548405. Classification of evidence: The results reported here provide Class I evidence that, for patients with active RRMS, alemtuzumab is superior to SC IFN-β-1a on multiple MRI endpoints.
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Affiliation(s)
- Douglas L Arnold
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA.
| | - Elizabeth Fisher
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Vesna V Brinar
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Jeffrey A Cohen
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Alasdair J Coles
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Gavin Giovannoni
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Hans-Peter Hartung
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Eva Havrdova
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Krzysztof W Selmaj
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Miroslav Stojanovic
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Howard L Weiner
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Stephen L Lake
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - David H Margolin
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - David R Thomas
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - Michael A Panzara
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
| | - D Alastair S Compston
- From NeuroRx Research (D.L.A.) and Department of Neurology and Neurosurgery (D.L.A.), Montréal Neurological Institute, McGill University, Québec, Canada; Department of Biomedical Engineering (E.F.) and Mellen Center (J.A.C.), Cleveland Clinic, OH; Zagreb Medical School and University Hospital Center (V.V.B.), Croatia; Department of Clinical Neurosciences (A.J.C., D.A.S.C.), University of Cambridge, UK; Queen Mary University of London (G.G.), Barts and the London School of Medicine, UK; Department of Neurology and Center for Neuropsychiatry (H.-P.H.), Heinrich-Heine University, Düsseldorf, Germany; Department of Neurology (E.H.), First Medical Faculty, Charles University in Prague, Czech Republic; Department of Neurology (K.W.S.), Medical University of Łódź, Poland; Clinical Centre Kragujevac (M.S.), Clinic of Neurology, Serbia; Brigham and Women's Hospital Center for Neurologic Diseases (H.L.W.), Boston, MA; Sanofi Genzyme (S.L.L., D.H.M., M.A.P.), Cambridge, MA; and Evidence Scientific Solutions (D.R.T.), Horsham, West Sussex, UK. Dr. Panzara is currently with Wave Life Sciences, Cambridge, MA
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28
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Ciampi E, Pareto D, Sastre-Garriga J, Vidal-Jordana A, Tur C, Río J, Tintoré M, Auger C, Rovira A, Montalban X. Grey matter atrophy is associated with disability increase in natalizumab-treated patients. Mult Scler 2016; 23:556-566. [DOI: 10.1177/1352458516656808] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Brain volume loss (BVL) is a key outcome in multiple sclerosis (MS) trials. Natalizumab is highly effective on inflammation with moderate impact on atrophy. Objective: To explore BVL in patients receiving natalizumab with an emphasis on grey matter (GM). Methods: We performed a retrospective post hoc analysis of BVL in 38 patients receiving natalizumab for 3 years using longitudinal voxel-based morphometry (VBM) and FreeSurfer. Results: Significant BVL was observed during first year: brain parenchymal fraction (BPF): −1.12% ( p < 0.001); white matter fraction (WMF): −0.9% ( p = 0.001); grey matter fraction (GMF): −1.28% ( p = 0.002). GM loss was found using VBM in bilateral cerebellum, cingulum, left > right fronto-parietal cortex, right > left hippocampus and left caudate. FreeSurfer showed significant volume losses in subcortical GM, brainstem and cerebellum, and cortical thinning in the left insula. In the second year, only WMF decrease (−0.6%; p = 0.015) was observed with no VBM changes, although FreeSurfer detected significant volume loss in thalamus, hippocampus and cerebellum. Baseline gadolinium enhancement influenced WMF and BPF changes during the first year, but not GMF. Patients with confirmed Expanded Disability Status Scale (EDSS) worsening at 3 years had lower baseline GMF and left thalamus volume and greater BVL over follow-up. Conclusion: BVL develops mainly during the first year of natalizumab therapy. GM changes are independent of baseline inflammation and correlate with disability.
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Affiliation(s)
- Ethel Ciampi
- Servei de Neurologia/Neuroimmunologia, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Deborah Pareto
- Servei de Radiologia, Unitat de Ressonància Magnètica, Institut de Diagnòstic per la Imatge (IDI), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Sastre-Garriga
- Servei de Neurologia/Neuroimmunologia, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Angela Vidal-Jordana
- Servei de Neurologia/Neuroimmunologia, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carmen Tur
- Servei de Neurologia/Neuroimmunologia, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Río
- Servei de Neurologia/Neuroimmunologia, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mar Tintoré
- Servei de Neurologia/Neuroimmunologia, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Auger
- Servei de Radiologia, Unitat de Ressonància Magnètica, Institut de Diagnòstic per la Imatge (IDI), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alex Rovira
- Servei de Radiologia, Unitat de Ressonància Magnètica, Institut de Diagnòstic per la Imatge (IDI), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Montalban
- Servei de Neurologia/Neuroimmunologia, Multiple Sclerosis Centre of Catalonia (Cemcat), Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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29
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Giovannoni G, Butzkueven H, Dhib-Jalbut S, Hobart J, Kobelt G, Pepper G, Sormani MP, Thalheim C, Traboulsee A, Vollmer T. Brain health: time matters in multiple sclerosis. Mult Scler Relat Disord 2016; 9 Suppl 1:S5-S48. [PMID: 27640924 DOI: 10.1016/j.msard.2016.07.003] [Citation(s) in RCA: 235] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 01/10/2023]
Abstract
INTRODUCTION We present international consensus recommendations for improving diagnosis, management and treatment access in multiple sclerosis (MS). Our vision is that these will be used widely among those committed to creating a better future for people with MS and their families. METHODS Structured discussions and literature searches conducted in 2015 examined the personal and economic impact of MS, current practice in diagnosis, treatment and management, definitions of disease activity and barriers to accessing disease-modifying therapies (DMTs). RESULTS Delays often occur before a person with symptoms suggestive of MS sees a neurologist. Campaigns to raise awareness of MS are needed, as are initiatives to improve access to MS healthcare professionals and services. We recommend a clear treatment goal: to maximize neurological reserve, cognitive function and physical function by reducing disease activity. Treatment should start early, with DMT and lifestyle measures. All parameters that predict relapses and disability progression should be included in the definition of disease activity and monitored regularly when practical. On suboptimal control of disease activity, switching to a DMT with a different mechanism of action should be considered. A shared decision-making process that embodies dialogue and considers all appropriate DMTs should be implemented. Monitoring data should be recorded formally in registries to generate real-world evidence. In many jurisdictions, access to DMTs is limited. To improve treatment access the relevant bodies should consider all costs to all parties when conducting economic evaluations and encourage the continuing investigation, development and use of cost-effective therapeutic strategies and alternative financing models. CONCLUSIONS The consensus findings of an international author group recommend a therapeutic strategy based on proactive monitoring and shared decision-making in MS. Early diagnosis and improved treatment access are also key components.
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Affiliation(s)
- Gavin Giovannoni
- Queen Mary University London, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK.
| | - Helmut Butzkueven
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia.
| | - Suhayl Dhib-Jalbut
- Department of Neurology, RUTGERS-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Jeremy Hobart
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK.
| | | | | | | | | | - Anthony Traboulsee
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Timothy Vollmer
- Department of Neurology, University of Colorado Denver, Aurora, CO, USA.
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30
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Jokubaitis VG, Spelman T, Kalincik T, Lorscheider J, Havrdova E, Horakova D, Duquette P, Girard M, Prat A, Izquierdo G, Grammond P, Van Pesch V, Pucci E, Grand'Maison F, Hupperts R, Granella F, Sola P, Bergamaschi R, Iuliano G, Spitaleri D, Boz C, Hodgkinson S, Olascoaga J, Verheul F, McCombe P, Petersen T, Rozsa C, Lechner-Scott J, Saladino ML, Farina D, Iaffaldano P, Paolicelli D, Butzkueven H, Lugaresi A, Trojano M. Predictors of long-term disability accrual in relapse-onset multiple sclerosis. Ann Neurol 2016; 80:89-100. [DOI: 10.1002/ana.24682] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 04/28/2016] [Accepted: 05/02/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Vilija G. Jokubaitis
- Department of Medicine and Melbourne Brain Centre at the Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
- Department of Neurology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Tim Spelman
- Department of Medicine and Melbourne Brain Centre at the Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
| | - Tomas Kalincik
- Department of Medicine and Melbourne Brain Centre at the Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
- Department of Neurology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Johannes Lorscheider
- Department of Medicine and Melbourne Brain Centre at the Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
- Department of Neurology; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Eva Havrdova
- Department of Neurology and Center of Clinical Neuroscience; First Faculty of Medicine, General University Hospital and Charles University in Prague; Prague Czech Republic
| | - Dana Horakova
- Department of Neurology and Center of Clinical Neuroscience; First Faculty of Medicine, General University Hospital and Charles University in Prague; Prague Czech Republic
| | - Pierre Duquette
- Centre Hospitalier de l'Université de Montréal , Notre Dame Hospital; Montreal Quebec Canada
| | - Marc Girard
- Centre Hospitalier de l'Université de Montréal , Notre Dame Hospital; Montreal Quebec Canada
| | - Alexandre Prat
- Centre Hospitalier de l'Université de Montréal , Notre Dame Hospital; Montreal Quebec Canada
| | | | - Pierre Grammond
- Centre de réadaptation déficience physique Chaudière-Appalache; Lévis Quebec Canada
| | | | - Eugenio Pucci
- Neurology Unit, Azienda Sanitaria Unica Regionale Marche AV3; Macerata Italy
| | | | | | | | - Patrizia Sola
- Nuovo Ospedale Civile S.Agostino/Estense; Modena Italy
| | | | | | - Daniele Spitaleri
- Azienda Ospedaliera di Rilievo Nazionale San Giuseppe Moscati; Avellino Italy
| | - Cavit Boz
- Karadeniz Technical University; Trabzon Turkey
| | - Suzanne Hodgkinson
- Department of Neurology; Liverpool Hospital; Liverpool New South Wales Australia
| | | | | | - Pamela McCombe
- Centre for Clinical Research; University of Queensland; Brisbane Queensland Australia
| | | | | | | | | | - Deborah Farina
- MS Center, Department of Neuroscience, Imaging and Clinical Sciences; G. d'Annunzio University; Chieti Italy
| | - Pietro Iaffaldano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs; University of Bari; Bari Italy
| | - Damiano Paolicelli
- Department of Basic Medical Sciences, Neuroscience and Sense Organs; University of Bari; Bari Italy
| | - Helmut Butzkueven
- Department of Medicine and Melbourne Brain Centre at the Royal Melbourne Hospital; University of Melbourne; Melbourne Victoria Australia
- Department of Neurology; Royal Melbourne Hospital; Melbourne Victoria Australia
- Department of Neurology, Box Hill Hospital; Monash University; Box Hill Victoria Australia
| | - Alessandra Lugaresi
- Department of Biomedical and Neuromotor Sciences (DIBINEM); Alma Mater Studiorum-University of Bologna; Bologna Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna; Bologna Italy
| | - Maria Trojano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs; University of Bari; Bari Italy
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Pozzi L, Schmidli H, Ohlssen DI. A Bayesian hierarchical surrogate outcome model for multiple sclerosis. Pharm Stat 2016; 15:341-8. [DOI: 10.1002/pst.1749] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 12/14/2015] [Accepted: 02/29/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Luca Pozzi
- Division of Biostatistics; University of California Berkeley; Berkeley 94720-7358 CA USA
| | - Heinz Schmidli
- Statistical Methodology, Development; Novartis Pharma AG; Basel Switzerland
| | - David I. Ohlssen
- Statistical Methodology, Development; Novartis Pharmaceuticals Corporation; East Hanover 07936-1080 NJ USA
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Bujkiewicz S, Thompson JR, Riley RD, Abrams KR. Bayesian meta-analytical methods to incorporate multiple surrogate endpoints in drug development process. Stat Med 2016; 35:1063-89. [PMID: 26530518 PMCID: PMC4950070 DOI: 10.1002/sim.6776] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 09/20/2015] [Accepted: 10/05/2015] [Indexed: 12/15/2022]
Abstract
A number of meta-analytical methods have been proposed that aim to evaluate surrogate endpoints. Bivariate meta-analytical methods can be used to predict the treatment effect for the final outcome from the treatment effect estimate measured on the surrogate endpoint while taking into account the uncertainty around the effect estimate for the surrogate endpoint. In this paper, extensions to multivariate models are developed aiming to include multiple surrogate endpoints with the potential benefit of reducing the uncertainty when making predictions. In this Bayesian multivariate meta-analytic framework, the between-study variability is modelled in a formulation of a product of normal univariate distributions. This formulation is particularly convenient for including multiple surrogate endpoints and flexible for modelling the outcomes which can be surrogate endpoints to the final outcome and potentially to one another. Two models are proposed, first, using an unstructured between-study covariance matrix by assuming the treatment effects on all outcomes are correlated and second, using a structured between-study covariance matrix by assuming treatment effects on some of the outcomes are conditionally independent. While the two models are developed for the summary data on a study level, the individual-level association is taken into account by the use of the Prentice's criteria (obtained from individual patient data) to inform the within study correlations in the models. The modelling techniques are investigated using an example in relapsing remitting multiple sclerosis where the disability worsening is the final outcome, while relapse rate and MRI lesions are potential surrogates to the disability progression.
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Affiliation(s)
- Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, University Road, Leicester, LE1 7RH, U.K
| | - John R Thompson
- Genetic Epidemiology Group, Department of Health Sciences, University of Leicester, University Road, Leicester, LE1 7RH, U.K
| | - Richard D Riley
- Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire, ST5 5BG, U.K
| | - Keith R Abrams
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, University Road, Leicester, LE1 7RH, U.K
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Matthews PM, Roncaroli F, Waldman A, Sormani MP, De Stefano N, Giovannoni G, Reynolds R. A practical review of the neuropathology and neuroimaging of multiple sclerosis. Pract Neurol 2016; 16:279-87. [PMID: 27009310 DOI: 10.1136/practneurol-2016-001381] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2016] [Indexed: 11/04/2022]
Abstract
The variability in the severity and clinical course of multiple sclerosis (MS) has as its basis an extreme heterogeneity in the location, nature and extent of pathology in the brain and spinal cord. Understanding the underlying neuropathology and associated pathogenetic mechanisms of the disease helps to communicate the rationale for treatment and disease monitoring to patients. Neuroimaging is an important tool for this: it allows clinicians to relate neuropathological changes to clinical presentations and to monitor the course of their disease. Here, we review MS neuropathology and its imaging correlates to provide a practical guide for using MRI to assess disease severity and treatment responses. This provides a foundation for optimal management of patients based on the principle that they show 'no evidence of disease activity'.
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Affiliation(s)
- Paul M Matthews
- Division of Brain Sciences, Department of Medicine, Imperial College London, London, UK
| | - Frederico Roncaroli
- Division of Brain Sciences, Department of Medicine, Imperial College London, London, UK Division of Neuroscience, University of Manchester, Manchester, UK
| | - Adam Waldman
- Division of Brain Sciences, Department of Medicine, Imperial College London, London, UK
| | - Maria Pia Sormani
- Division of Brain Sciences, Department of Medicine, Imperial College London, London, UK University of Genoa, Genoa, Liguria, Italy
| | - Nicola De Stefano
- Division of Brain Sciences, Department of Medicine, Imperial College London, London, UK Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | | | - Richard Reynolds
- Division of Brain Sciences, Department of Medicine, Imperial College London, London, UK
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Stone LA, Cutter GR, Fisher E, Richert N, McCartin J, Ohayon J, Bash C, McFarland H. Relapse May Serve as a Mediator Variable in Longitudinal Outcomes in Multiple Sclerosis. J Neuroimaging 2015; 26:296-302. [PMID: 26686343 DOI: 10.1111/jon.12321] [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: 06/27/2015] [Accepted: 11/02/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND/PURPOSE Contrast-enhancing lesions (CEL) on magnetic resonance imaging (MRI) are believed to represent inflammatory disease activity in multiple sclerosis (MS), but their relationship to subsequent long-term disability and progression is unclear, particularly at longer time periods such as 8-10 years. METHODS Between 1989 and 1994, 111 MS patients were seen at the National Institutes of Health for clinical evaluations and 3 monthly contrast-enhanced MRI scans. Of these, 94 patients were re-evaluated a mean of 8 years later (range 6.1-10.5 years) with a single MRI scan and clinical evaluation. CEL number and volume were determined at baseline and follow-up. The number of relapses was ascertained over the follow-up period and annualized relapse rates were calculated. Other MRI parameters, such as T2 hyperintensity volume, T1 volume, and brain parenchymal fraction, were also calculated. RESULTS While there was no direct correlation between CEL number or volume at baseline and disability status at follow-up, CEL measures at baseline did correlate with number of relapses observed in the subsequent years, and the number of relapses in turn correlated with subsequent disability as well as transition to progressive MS. CONCLUSION While number and volume of CEL at baseline do not directly correlate with disability in the longer term in MS, our data suggest that 1 route to disability involves relapses as a mediator variable in the causal sequence of MS progression from CEL to disability. Further studies using relapse as a mediator variable in a larger data set may be warranted.
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Affiliation(s)
- Lael Anne Stone
- Mellen Center for Treatment and Research, Cleveland Clinic Foundation, Cleveland, OH
| | | | | | | | - Jennifer McCartin
- Neuroimmunology Branch of the National Institute of Neurological Disorders and Stroke, Bethesda, MD
| | - Joan Ohayon
- Neuroimmunology Branch of the National Institute of Neurological Disorders and Stroke, Bethesda, MD
| | - Craig Bash
- Department of Neuroradiology, Uniformed Services School of Medicine, Bethesda, MD
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Relapses Requiring Intravenous Steroid Use and Multiple-Sclerosis-related Hospitalizations: Integrated Analysis of the Delayed-release Dimethyl Fumarate Phase III Studies. Clin Ther 2015; 37:2543-51. [PMID: 26526385 DOI: 10.1016/j.clinthera.2015.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 09/21/2015] [Accepted: 09/23/2015] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose was to report the effects of delayed-release dimethyl fumarate (DMF; also known as gastro-resistant DMF) on the number of relapses requiring intravenous (IV) steroids and multiple sclerosis (MS)-related hospitalizations using integrated data from the Phase III DEFINE and CONFIRM studies. METHODS DEFINE and CONFIRM were randomized, double-blind, placebo-controlled, multicenter studies that evaluated the efficacy and safety of DMF over a 2-year period in patients with relapsing-remitting MS (RRMS). Patients were randomized (1:1:1) to receive oral DMF 240 mg BID or TID, placebo, or glatiramer acetate (CONFIRM only). Eligible subjects (aged 18-55 years) had an EDSS score of 0-5.0 and experienced either ≥1 relapse in the 12 months or had ≥1 gadolinium-enhanced lesion on brain MRI in the 6 weeks, before randomization. Data DEFINE and CONFIRM were pooled and analyzed using a negative binomial regression model (adjusted for study and region). Data obtained after subjects switched to an alternative MS therapy were not included in the analysis. Only relapses confirmed by the Independent Neurology Evaluation Committee were included in the analysis of relapses requiring IV steroids. FINDINGS The study population (intention-to-treat) comprised 2301 patients who received either placebo (n = 771), DMF BID (n = 769), or DMF TID (n = 761). Baseline demographic and disease characteristics were generally well balanced among treatment groups. Throughout the 2-year studies, the total number of relapses treated with methylprednisolone was 402, 221, and 209 in the placebo, DMF BID, and DMF TID groups, respectively. A smaller proportion of patients in the DMF BID (168 of 769 [21.8%]) and DMF TID (151 of 761 [19.8%]) groups experienced ≥1 relapse requiring IV steroids compared with the placebo group (284 of 771 [36.8%]). The total number of MS-related hospitalizations over 2 years was 136, 94, and 74 in the placebo, DMF BID, and DMF TID groups. A smaller proportion of patients in the DMF BID (73 of 769 [9.5%]) and DMF TID (57 of 761 [7.5%]) groups had ≥1 MS-related hospitalization compared with the placebo group (104 of 771 [13.5%]). IMPLICATIONS DMF is an effective and well tolerated therapy for RRMS. In addition to clinical benefits, the use of DMF may be associated with reduced patient burden and health economic savings, resulting from a decrease in resource utilization associated with relapses. ClinicalTrials.gov identifiers: NCT00420212 and NCT00451451.
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36
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van Munster CE, Jonkman LE, Weinstein HC, Uitdehaag BM, Geurts JJ. Gray matter damage in multiple sclerosis: Impact on clinical symptoms. Neuroscience 2015; 303:446-61. [DOI: 10.1016/j.neuroscience.2015.07.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 06/29/2015] [Accepted: 07/01/2015] [Indexed: 01/12/2023]
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Bujkiewicz S, Thompson JR, Spata E, Abrams KR. Uncertainty in the Bayesian meta-analysis of normally distributed surrogate endpoints. Stat Methods Med Res 2015; 26:2287-2318. [PMID: 26271918 PMCID: PMC5642004 DOI: 10.1177/0962280215597260] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We investigate the effect of the choice of parameterisation of meta-analytic models and related uncertainty on the validation of surrogate endpoints. Different meta-analytical approaches take into account different levels of uncertainty which may impact on the accuracy of the predictions of treatment effect on the target outcome from the treatment effect on a surrogate endpoint obtained from these models. A range of Bayesian as well as frequentist meta-analytical methods are implemented using illustrative examples in relapsing–remitting multiple sclerosis, where the treatment effect on disability worsening is the primary outcome of interest in healthcare evaluation, while the effect on relapse rate is considered as a potential surrogate to the effect on disability progression, and in gastric cancer, where the disease-free survival has been shown to be a good surrogate endpoint to the overall survival. Sensitivity analysis was carried out to assess the impact of distributional assumptions on the predictions. Also, sensitivity to modelling assumptions and performance of the models were investigated by simulation. Although different methods can predict mean true outcome almost equally well, inclusion of uncertainty around all relevant parameters of the model may lead to less certain and hence more conservative predictions. When investigating endpoints as candidate surrogate outcomes, a careful choice of the meta-analytical approach has to be made. Models underestimating the uncertainty of available evidence may lead to overoptimistic predictions which can then have an effect on decisions made based on such predictions.
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Affiliation(s)
- Sylwia Bujkiewicz
- 1 Biostatistics Research Group, Department of Health Sciences, University of Leicester, University Road, Leicester, UK
| | - John R Thompson
- 2 Genetic Epidemiology Group, Department of Health Sciences, University of Leicester, University Road, Leicester, UK
| | - Enti Spata
- 1 Biostatistics Research Group, Department of Health Sciences, University of Leicester, University Road, Leicester, UK
| | - Keith R Abrams
- 1 Biostatistics Research Group, Department of Health Sciences, University of Leicester, University Road, Leicester, UK
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38
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Freedman MS, Abdoli M. Evaluating response to disease-modifying therapy in relapsing multiple sclerosis. Expert Rev Neurother 2015; 15:407-23. [DOI: 10.1586/14737175.2015.1023711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
PURPOSE OF REVIEW We summarize MRI measures currently available to assess treatment efficacy and safety in multiple sclerosis (MS) clinical trials and discuss novel metrics that could enter the clinical arena in the near future. RECENT FINDINGS In relapsing remitting MS, MRI measures of disease activity (new T2 and gadolinium-enhancing lesions) provide a good surrogacy of treatment effect on relapse rate and disability progression; however, their value in progressive MS remains elusive. For the progressive disease forms, these measures need to be combined with quantities assessing the extent of irreversible tissue loss, which have already been introduced in some clinical trials (e.g., evolution of active lesions into permanent black holes and brain atrophy). Novel measures (e.g., quantification of gray matter and spinal cord atrophy) have demonstrated a great value in explaining patients' clinical outcome, but still need to be fully validated. Despite showing promise, evaluations of cortical lesions, of microscopic tissue abnormalities, and of functional cortical reorganization are still some way off for monitoring of treatment effects. SUMMARY Trial outcomes in MS should include measures of inflammation and neurodegeneration, which should be combined according to the disease clinical phenotype, phase of the study, and the supposed mechanism of action of the drug tested.
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40
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Natalizumab reduces relapse clinical severity and improves relapse recovery in MS. Mult Scler Relat Disord 2014; 3:705-11. [DOI: 10.1016/j.msard.2014.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 08/27/2014] [Accepted: 08/31/2014] [Indexed: 11/22/2022]
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Limmroth V, Barkhof F, Desem N, Diamond MP, Tachas G. CD49d antisense drug ATL1102 reduces disease activity in patients with relapsing-remitting MS. Neurology 2014; 83:1780-8. [PMID: 25239835 PMCID: PMC4240428 DOI: 10.1212/wnl.0000000000000926] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: This study evaluated the efficacy and safety of ATL1102, an antisense oligonucleotide that selectively targets the RNA for human CD49d, the α subunit of very late antigen 4, in patients with relapsing-remitting multiple sclerosis (RRMS). Methods: In a multicenter, double-blind, placebo-controlled randomized phase II trial, 77 patients with RRMS were treated with 200 mg of ATL1102 subcutaneously injected 3 times in the first week and twice weekly for 7 weeks or placebo and monitored for a further 8 weeks. MRI scans were taken at baseline and weeks 4, 8, 12, and 16. The primary endpoint was the cumulative number of new active lesions (either new gadolinium-enhancing T1 lesions or nonenhancing new or enlarging T2 lesions) at weeks 4, 8, and 12. Results: A total of 72 patients completed the study and 74 intention-to-treat patients were assessed. ATL1102 significantly reduced the cumulative number of new active lesions by 54.4% compared to placebo (mean 3.0 [SD 6.12] vs 6.2 [9.89], p = 0.01). The cumulative number of new gadolinium-enhancing T1 lesions was reduced by 67.9% compared to placebo (p = 0.002). Treatment-emergent adverse events included mild to moderate injection site erythema and decrease in platelet counts that returned to within the normal range after dosing. Conclusions: In patients with RRMS, ATL1102 significantly reduced disease activity after 8 weeks of treatment and was generally well-tolerated. This trial provides evidence for the first time that antisense oligonucleotides may be used as a therapeutic approach in neuroimmunologic disorders. Classification: This study provides Class I evidence that for patients with RRMS, the antisense oligonucleotide ATL1102 reduces the number of new active head MRI lesions.
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Affiliation(s)
- Volker Limmroth
- From the Department of Neurology (V.L.), Cologne City Hospitals, University of Cologne, Germany; the Department of Radiology (F.B.), VU Medical Centre, Amsterdam, the Netherlands; and Antisense Therapeutics Ltd. (N.D., M.P.D., G.T.), Melbourne, Australia
| | - Frederik Barkhof
- From the Department of Neurology (V.L.), Cologne City Hospitals, University of Cologne, Germany; the Department of Radiology (F.B.), VU Medical Centre, Amsterdam, the Netherlands; and Antisense Therapeutics Ltd. (N.D., M.P.D., G.T.), Melbourne, Australia
| | - Nuket Desem
- From the Department of Neurology (V.L.), Cologne City Hospitals, University of Cologne, Germany; the Department of Radiology (F.B.), VU Medical Centre, Amsterdam, the Netherlands; and Antisense Therapeutics Ltd. (N.D., M.P.D., G.T.), Melbourne, Australia
| | - Mark P Diamond
- From the Department of Neurology (V.L.), Cologne City Hospitals, University of Cologne, Germany; the Department of Radiology (F.B.), VU Medical Centre, Amsterdam, the Netherlands; and Antisense Therapeutics Ltd. (N.D., M.P.D., G.T.), Melbourne, Australia
| | - George Tachas
- From the Department of Neurology (V.L.), Cologne City Hospitals, University of Cologne, Germany; the Department of Radiology (F.B.), VU Medical Centre, Amsterdam, the Netherlands; and Antisense Therapeutics Ltd. (N.D., M.P.D., G.T.), Melbourne, Australia.
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Agius M, Meng X, Chin P, Grinspan A, Hashmonay R. Fingolimod therapy in early multiple sclerosis: an efficacy analysis of the TRANSFORMS and FREEDOMS studies by time since first symptom. CNS Neurosci Ther 2014; 20:446-51. [PMID: 24684973 DOI: 10.1111/cns.12235] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 01/09/2014] [Accepted: 01/12/2014] [Indexed: 02/03/2023] Open
Abstract
AIMS The phase 3 TRANSFORMS and FREEDOMS studies established the efficacy of fingolimod in reducing multiple sclerosis (MS) relapses and magnetic resonance imaging lesions compared with intramuscular (IM) interferon (IFN) β-1a and placebo over 12 and 24 months, respectively. METHODS To investigate the efficacy of fingolimod at the approved 0.5 mg dose in patients early in the MS disease course, post hoc subgroup analyses of TRANSFORMS (n = 272) and FREEDOMS (n = 217) data were conducted in patients who experienced their first MS symptom <3 years before randomization. RESULTS Fingolimod 0.5 mg reduced annualized relapse rate by 73.4% (P = 0.0002) versus IFNβ-1a IM and by 67.4% (P < 0.0001) versus placebo in patients with <3 years since first symptom; respective reductions were 45.4% and 51.4% in subgroups of patients with ≥3 years since first symptom. For patients with <3 years since their first symptom, significantly fewer new/newly enlarged T2 lesions were observed with fingolimod versus IFNβ-1a IM (mean number, 1.94 vs. 2.95; P = 0.036) or placebo (4.1 vs. 10.7; P < 0.001); the mean number of gadolinium-enhancing T1 lesions was significantly reduced versus placebo (0.3 vs. 1.1; P < 0.001). CONCLUSION Fingolimod 0.5 mg is highly effective in reducing relapses and MRI activity in patients early in the MS disease course.
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Affiliation(s)
- Mark Agius
- Department of Neurology, University of California Davis, Davis, CA, USA; Veteran's Affairs Northern California Health Care System, Mather, CA, USA
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Sormani MP, De Stefano N. MRI measures should be a primary outcome endpoint in Phase III randomized, controlled trials in multiple sclerosis: Yes. Mult Scler 2014; 20:280-1. [DOI: 10.1177/1352458513507360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Maria Pia Sormani
- Biostatistics Unit, Department of Health Sciences, University of Genoa, Italy
| | - Nicola De Stefano
- Department of Medicine Surgery and Neuroscience, University of Siena, Italy
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Berkovich R, Agius MA. Mechanisms of action of ACTH in the management of relapsing forms of multiple sclerosis. Ther Adv Neurol Disord 2014; 7:83-96. [PMID: 24587825 PMCID: PMC3932770 DOI: 10.1177/1756285613518599] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Acute and subacute inflammation, the mechanisms by which demyelination and axonal loss occur in multiple sclerosis (MS), result from the migration of activated immune cells into the central nervous system parenchyma. The triggering antigen is unknown, but the process involves deregulated immune response of T and B lymphocytes, macrophages, and mediators with expansion of autoreactive T cells creating a shift in the balance of pro- and anti-inflammatory cytokines favoring inflammation. Ongoing disease activity and exacerbations early in the course of relapsing-remitting MS may prevent full remission and propagate future progressive disability. A key strategy of immune therapy is timely initiation of treatment to achieve remission, followed by maintenance of remission. In this context, treatment with high-dose methylprednisolone (MP) is currently recommended to induce a faster recovery from a clinical exacerbation that results from an acute inflammatory attack. Adrenocorticotropic hormone (ACTH or corticotropin) gel is an alternative for patients who do not respond to or do not tolerate corticosteroids. ACTH is a universal agonist in the melanocortin (MC) system and, as such, among other functions, stimulates the adrenal cortex to produce cortisol. MCs are a family of peptides that includes ACTH and other MC peptides. This system has five classes of receptors, all of which show a strong affinity for ACTH, suggesting a more complex and dynamic mechanism than only inducing endogenous corticosteroid production. ACTH and MCs regulate processes relevant to MS, including anti-inflammatory and immunomodulatory functions involving lymphocytes, macrophages, the sympathetic nervous system involved in inflammatory processes, and reduction of pro-inflammatory cytokines. The clinical implications of the mechanistic differences between corticosteroid and ACTH gel treatment remain to be elucidated. Recent data show that patients experiencing an acute exacerbation, who previously had suboptimal response to or were unable to tolerate MP treatment, showed positive clinical outcomes with fewer adverse events with ACTH gel.
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Affiliation(s)
- Regina Berkovich
- Assistant Professor of Clinical Neurology, USC MS Comprehensive Care Center and Research Group, 1520 San Pablo St, 3000, Los Angeles, CA 90033, USA
| | - Mark A Agius
- University of California Davis, Sacramento, CA, USA
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45
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Matthews PM, Geraghty OC. Understanding the pharmacology of stroke and multiple sclerosis through imaging. Curr Opin Pharmacol 2014; 14:34-41. [PMID: 24565010 DOI: 10.1016/j.coph.2013.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/27/2013] [Accepted: 10/30/2013] [Indexed: 01/09/2023]
Abstract
Stroke and multiple sclerosis (MS) illustrate how clinical imaging can facilitate early phase drug development and most effective medicine use in the clinic. Imaging has enhanced understanding of the dynamics of evolution of disease pathophysiology, better defining treatment targets. Imaging measures can enable stratification of patients for clinical trials and for most cost-effective use in the clinic. In MS, imaging has allowed smaller Phase II clinical trials and contributed to medicine differentiation. It also has led to consideration of suppression of inflammation and neurodegeneration as meaningfully distinct pharmacodynamic concepts. Similar imaging measures can be used in preclinical and clinical studies. Testing translational pharmacological hypotheses using clinical imaging more explicitly could improve the success of the next generation of stroke therapeutics.
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Affiliation(s)
- Paul M Matthews
- Division of Brain Sciences, Department of Medicine, Imperial College London, UK; Neurosciences Therapeutic Area Unit, GlaxoSmithKline Research and Development, Brentford, UK.
| | - Olivia C Geraghty
- Division of Brain Sciences, Department of Medicine, Imperial College London, UK
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Cook SD, Dhib-Jalbut S, Dowling P, Durelli L, Ford C, Giovannoni G, Halper J, Harris C, Herbert J, Li D, Lincoln JA, Lisak R, Lublin FD, Lucchinetti CF, Moore W, Naismith RT, Oehninger C, Simon J, Sormani MP. Use of Magnetic Resonance Imaging as Well as Clinical Disease Activity in the Clinical Classification of Multiple Sclerosis and Assessment of Its Course: A Report from an International CMSC Consensus Conference, March 5-7, 2010. Int J MS Care 2014; 14:105-14. [PMID: 24453741 DOI: 10.7224/1537-2073-14.3.105] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
It has recently been suggested that the Lublin-Reingold clinical classification of multiple sclerosis (MS) be modified to include the use of magnetic resonance imaging (MRI). An international consensus conference sponsored by the Consortium of Multiple Sclerosis Centers (CMSC) was held from March 5 to 7, 2010, to review the available evidence on the need for such modification of the Lublin-Reingold criteria and whether the addition of MRI or other biomarkers might lead to a better understanding of MS pathophysiology and disease course over time. The conference participants concluded that evidence of new MRI gadolinium-enhancing (Gd+) T1-weighted lesions and unequivocally new or enlarging T2-weighted lesions (subclinical activity, subclinical relapses) should be added to the clinical classification of MS in distinguishing relapsing inflammatory from progressive forms of the disease. The consensus was that these changes to the classification system would provide more rigorous definitions and categorization of MS course, leading to better insights as to the evolution and treatment of MS.
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Affiliation(s)
- Stuart D Cook
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Suhayl Dhib-Jalbut
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Peter Dowling
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Luca Durelli
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Corey Ford
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Gavin Giovannoni
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - June Halper
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Colleen Harris
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Joseph Herbert
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - David Li
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - John A Lincoln
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Robert Lisak
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Fred D Lublin
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Claudia F Lucchinetti
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Wayne Moore
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Robert T Naismith
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Carlos Oehninger
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Jack Simon
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
| | - Maria Pia Sormani
- University of Medicine and Dentistry of New Jersey, Newark, NJ, USA (SDC); Department of Neurology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ (SDJ); VA Medical Center-East Orange, East Orange, NJ, USA (PD); Department of Clinical and Biological Sciences, San Luigi Gonzaga Medical School, University of Torino, Orbassano, Italy (LD); Multiple Sclerosis Clinic, University of New Mexico Health Sciences Center, Albuquerque, NM, USA (CF); Queen Mary University of London, Blizard Institute, Barts and The London School of Medicine and Dentistry, Whitechapel, London, UK (GG); Consortium of Multiple Sclerosis Centers, Hackensack, NJ, USA (J Halper); Multiple Sclerosis Clinic, Foothills Medical Centre, Calgary, Alberta, Canada (CH); MS Comprehensive Care Center, NYU Langone Medical Center, New York, NY, USA (J Herbert); MS Clinic, University of British Columbia Hospital, Vancouver, British Columbia, Canada (DL); MS Research Group, University of Texas Health, Houston, TX, USA (JAL); Comprehensive Clinical and Research MS Center, Wayne State University, Detroit, MI, USA (RL); Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA (FDL); Department of Neurology, Mayo Clinic, Rochester, MN, USA (CFL); Vancouver General Hospital, Vancouver, British Columbia, Canada (WM); Department of Neurology, Washington University, St. Louis, MO, USA (RTN); LACTRIMS and Institute of Neurology, Montevideo, Uruguay (CO); VA Medical Center, Portland, OR, USA (JS); and Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy (MPS)
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Kieseier BC. The challenges of measuring disability accumulation in relapsing–remitting multiple sclerosis: evidence from interferon beta treatments. Expert Rev Neurother 2014; 14:105-20. [DOI: 10.1586/14737175.2014.869478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sormani MP, Arnold DL, De Stefano N. Treatment effect on brain atrophy correlates with treatment effect on disability in multiple sclerosis. Ann Neurol 2014; 75:43-9. [PMID: 24006277 DOI: 10.1002/ana.24018] [Citation(s) in RCA: 217] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/23/2013] [Accepted: 08/24/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the extent to which treatment effect on brain atrophy is able to mediate, at the trial level, the treatment effect on disability progression in relapsing-remitting multiple sclerosis (RRMS). METHODS We collected all published randomized clinical trials in RRMS lasting at least 2 years and including as endpoints disability progression (defined as 6 or 3 months confirmed 1-point increase on the Expanded Disability Status Scale), active magnetic resonance imaging (MRI) lesions (defined as new/enlarging T2 lesions), and brain atrophy (defined as change in brain volume between month 24 and month 6-12). Treatment effects were expressed as relative reductions. A linear regression, weighted for trial size and duration, was used to assess the relationship between the treatment effects on MRI markers and on disability progression. RESULTS Thirteen trials including >13,500 RRMS patients were included in the meta-analysis. Treatment effects on disability progression were correlated with treatment effects both on brain atrophy (R(2) = 0.48, p = 0.001) and on active MRI lesions (R(2) = 0.61, p < 0.001). When the effects on both MRI endpoints were included in a multivariate model, the correlation was higher (R(2) = 0.75, p < 0.001), and both variables were retained as independently related to the treatment effect on disability progression. INTERPRETATION In RRMS, the treatment effect on brain atrophy is correlated with the effect on disability progression over 2 years. This effect is independent of the effect of active MRI lesions on disability; the 2 MRI measures predict the treatment effect on disability more closely when used in combination.
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Affiliation(s)
- Maria Pia Sormani
- Biostatistics Unit, Department of Health Sciences, University of Genoa, Genoa, Italy
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Scalfari A, Neuhaus A, Daumer M, Muraro PA, Ebers GC. Onset of secondary progressive phase and long-term evolution of multiple sclerosis. J Neurol Neurosurg Psychiatry 2014; 85:67-75. [PMID: 23486991 DOI: 10.1136/jnnp-2012-304333] [Citation(s) in RCA: 185] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess factors affecting the rate of conversion to secondary progressive (SP) multiple sclerosis (MS) and its subsequent evolution. METHODS Among 806 patients with relapsing remitting (RR) onset MS from the London Ontario database, we used Kaplan-Meier, Cox regression and multiple logistic regression analyses to investigate the effect of baseline clinical and demographic features on (1) the probability of, and the time to, SP disease, (2) the time to bedbound status (Disability Status Scale (DSS 8)) from onset of progression. RESULTS The risk of entering the SP phase increased proportionally with disease duration (OR=1.07 for each additional year; p<0.001). Shorter latency to SP was associated with shorter times to severe disability. The same association was found even when patients were grouped by number of total relapses before progression. However, the evolution of the SP phase was not influenced by the duration of the RR phase. Male sex (HR=1.41; p<0.001), older age at onset (age ≤20 and 21-30 vs >30 HR=0.52 (p<0.001), 0.65 (p<0.001), respectively) and high early relapse frequency (1-2 attacks vs ≥3 HR=0.63 (p<0.001), 0.75 (p=0.04), respectively) predicted significantly higher risk of SP MS and shorter latency to progression. Times to DSS 8 from onset of progression were significantly shorter among those with high early relapse frequency (≥3 attacks), and among those presenting with cerebellar and brainstem symptoms. CONCLUSIONS The onset of SP MS is the dominant determinant of long-term prognosis, and its prevention is the most important target measure for treatment. Baseline clinical features of early relapse frequency and age at onset can be used to select groups at higher risk of developing severe disability based on the probability of their disease becoming progressive within a defined time period.
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Affiliation(s)
- Antonio Scalfari
- Division of Experimental Medicine, Centre for Neuroscience, Imperial College London, , London, UK
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Fahrbach K, Huelin R, Martin AL, Kim E, Dastani HB, Rao S, Malhotra M. Relating relapse and T2 lesion changes to disability progression in multiple sclerosis: a systematic literature review and regression analysis. BMC Neurol 2013; 13:180. [PMID: 24245966 PMCID: PMC4225567 DOI: 10.1186/1471-2377-13-180] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 11/04/2013] [Indexed: 12/15/2022] Open
Abstract
Background In the treatment of multiple sclerosis (MS), the most important therapeutic aim of disease-modifying treatments (DMTs) is to prevent or postpone long-term disability. Given the typically slow progression observed in the majority of relapsing-remitting MS (RRMS) patients, the primary endpoint for most randomized clinical trials (RCTs) is a reduction in relapse rate. It is widely assumed that reducing relapse rate will slow disability progression. Similarly, MRI studies suggest that reducing T2 lesions will be associated with slowing long-term disability in MS. The objective of this study was to evaluate the relationship between treatment effects on relapse rates and active T2 lesions to differences in disease progression (as measured by the Expanded Disability Status Scale [EDSS]) in trials evaluating patients with clinically isolated syndrome (CIS), RRMS, and secondary progressive MS (SPMS). Methods A systematic literature review was conducted in Medline, Embase, CENTRAL, and PsycINFO to identify randomized trials published in English from January 1, 1993-June 3, 2013 evaluating DMTs in adult MS patients using keywords for CIS, RRMS, and SPMS combined with keywords for relapse and recurrence. Eligible studies were required to report outcomes of relapse and T2 lesion changes or disease progression in CIS, RRMS, or SPMS patients receiving DMTs and have a follow-up duration of at least 22 months. Ultimately, 40 studies satisfied these criteria for inclusion. Regression analyses were conducted on RCTs to relate differences between the effect of treatments on relapse rates and on active T2 lesions to differences between the effects of treatments on disease progression (as measured by EDSS). Results Regression analysis determined there is a substantive clinically and statistically significant association between concurrent treatment effects in relapse rate and EDSS; p < 0.01. Lower treatment effects were associated with higher relative rates of disease progression. Significant associations between T2 lesion measures and EDSS measures also were found (p < 0.05), with some suggestion that the strength of the association may differ for older versus newer DMTs. Conclusions Treatment differences in relapse reduction and T2 lesions are positively related to differences in disease progression over the first two years of treatment.
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Affiliation(s)
- Kyle Fahrbach
- Evidera, 430 Bedford Street, Suite 300, Lexington, MA 02420, USA.
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