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Piedrabuena MA, Correale J, Fiol M, Marrodan M, Rojas JI, Alonso M, Pappolla A, Miguez J, Patrucco L, Cristiano E, Vrech C, Cohen L, Alonso R, Silva B, Luetic G, Deri N, Burgos M, Liwacki S, Piedrabuena R, Tkachuk V, Barboza A, Martinez A, Balbuena ME, Pinheiro AA, Nofal P, Lopez PA, Tavolini D, Leguizamon F, Hryb JP, Tizio S, Recchia L, Reich E, Contentti EC, Marcilla MP, Pagani F, Cabrera LM, Curbelo MC, Mainella C, Liguori NF, Coppola M, Pettinicchi JP, Carra A, Jose G, Nadur D, Bestoso S, Pestchanker C, Vazquez GD, Martinez CM, Ysrraelit MC. Selection of disease modifying therapies in multiple sclerosis based on patient's age and disease activity: Data from a nationwide registry. J Neurol Sci 2024; 461:123052. [PMID: 38797140 DOI: 10.1016/j.jns.2024.123052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 05/09/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Knowledge of the safety and efficacy of disease-modifying therapies (DMTs) in older patients with Multiple Sclerosis (pwMS) is limited due to their exclusion from clinical trials. Our purpose is to evaluate the choice of DMTs in pwMS older than 50 years old in a real-world setting. METHODS Cross-sectional study of pwMS from the Argentine MS and NMOSD Registry. We included patients under 35 and above 50 years old prescribed DMTs. Disease activity was categorized as highly active (HA) or not highly active (NHA), and DMTs were classified as low efficacy therapies (LET) or high efficacy therapies (HET). RESULTS 1460 patients (65% females) were enrolled. The HA group comprised 241 patients, 198 young (82.2%) and 43 older (17.8%). The NHA group included 1219 patients, 893 young (73%) and 326 older (27%). In the NHA group, older patients received LET more frequently than younger patients (66% versus 44%; p < 0.01). In the HA group, older patients received LET in 61% of cases, whereas younger patients received HET in 71% (p = 0.01). CONCLUSION The study shows the preference of LET in older patients regardless of disease activity. However it does not demonstrate a difference in disability in older patients based on low vs high efficacy DMTs used, probably due to the design of the study. Further longitudinal studies are warranted to address this issue.
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Affiliation(s)
| | - Jorge Correale
- Departamento de Neuroinmunología - FLENI, CABA, Argentina; Profesor honorario de la facultad de farmacia y bioquimica, Universidad de Buenos Aires, Argentina
| | - Marcela Fiol
- Departamento de Neuroinmunología - FLENI, CABA, Argentina
| | | | - Juan I Rojas
- Hospital Universitario de CEMIC, CABA, Argentina
| | - Marina Alonso
- Servicio de clínica médica, Hospital Italiano de Buenos Aires, CABA, Argentina
| | - Agustín Pappolla
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jimena Miguez
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Liliana Patrucco
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Leila Cohen
- Centro universitario de esclerosis múltiple (CUEM), Hospital Ramos Mejía, CABA, Argentina
| | - Ricardo Alonso
- Centro Universitario de Esclerosis Múltiple, Hospital Ramos Mejía. / Servicio de neurología, Sanatorio Güemes, Argentina
| | - Berenice Silva
- Servicio de Neurología, Hospital Italiano de Buenos Aires, Buenos Aires / Centro universitario de esclerosis múltiple (CUEM), Hospital Ramos Mejía, CABA, Argentina
| | | | - Norma Deri
- Centro de Especialidades Neurológicas y Rehabilitación (CENyR), Argentina
| | - Marcos Burgos
- Servicio de Neurología, Hospital San Bernardo, Salta, Argentina
| | | | - Raul Piedrabuena
- Clínica Universitaria Reina Fabiola, Córdoba, Instituto Lennox, Córdoba, Argentina
| | - Verónica Tkachuk
- Neuroinmunologia Hospital de Clínicas "José de san Martin", CABA, Argentina
| | - Andres Barboza
- Servicio de Neurología, Hospital Central Mendoza, Mendoza, Argentina
| | - Alejandra Martinez
- Sección de Enfermedades Desmielinizantes - Hospital Británico, CABA, Argentina
| | - Maria E Balbuena
- Neuroinmunologia Hospital de Clínicas "José de san Martin", CABA, Argentina
| | | | - Pedro Nofal
- Hospital de Clínicas Nuestra Señora del Carmen, San Miguel de Tucumán, Tucumán, Argentina
| | - Pablo A Lopez
- Neuroimmunology Unit, Department of Neurosciences, Hospital Alemán, Buenos Aires, Argentina
| | - Dario Tavolini
- INECO Neurociencias Oroño - Fundación INECO, Rosario, Santa Fe, Argentina
| | | | - Javier P Hryb
- Neuroinmunología Clínica y Enfermedades Desmielinizantes. Hospital Carlos G Durand, CABA, Argentina
| | | | - Luciano Recchia
- Servicio de Neurología, Hospital Central Mendoza, Mendoza, Argentina
| | | | | | | | - Fatima Pagani
- Instituto de Neurociencias Fundación Favaloro, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | - Maria C Curbelo
- Sección de Enfermedades Desmielinizantes - Hospital Británico, CABA, Argentina
| | | | | | | | - Juan P Pettinicchi
- Neuroimmunology Unit, Department of Neurosciences, Hospital Alemán, Buenos Aires, Argentina
| | - Adriana Carra
- Sección de Enfermedades Desmielinizantes - Hospital Británico, CABA, Argentina
| | - Gustavo Jose
- Clínica San Jorge, Ushuaia, Tierra del fuego, Argentina
| | | | - Santiago Bestoso
- Servicio de Neurología - Hospital Escuela José F. de San Martín Corrientes, Corrientes, Argentina
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Gelibter S, Saraceno L, Pirro F, Susani EL, Protti A. As time goes by: Treatment challenges in elderly people with multiple sclerosis. J Neuroimmunol 2024; 391:578368. [PMID: 38761652 DOI: 10.1016/j.jneuroim.2024.578368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/11/2024] [Accepted: 05/12/2024] [Indexed: 05/20/2024]
Abstract
A demographic shift in multiple sclerosis (MS) is leading to an increased number of elderly people with MS (pwMS) and a rise in late-onset MS (LOMS) cases. This shift adds complexity to the treatment management of these patients, due to enhanced treatment-associated risks and the possible interplay between immunosenescence and disease-modifying therapies (DMTs). In the present paper, we performed a systematic review of the current evidence concerning the relationship between aging and treatment management in elderly pwMS. Our literature search identified 35 original studies relevant to this topic. The gathered evidence consistently indicates a diminished efficacy of DMTs in older pwMS, particularly in preventing disability accrual. Against this background, high-efficacy therapies (HETs) appear to show less benefit over moderate-low-efficacy DMTs in older patients. These data mainly derive from observational retrospective studies or meta-analyses conducted on randomized clinical trials (RCTs). RCTs, however, exclude pwMS older than 55 years, limiting our ability to acquire robust evidence regarding this patient group. Regarding treatment discontinuation in elderly pwMS with stable disease, the available data, which mainly focuses on older injectable DMTs, suggests that their suspension appears to be relatively safe in terms of disease activity. Nevertheless, the first RCT specifically targeting treatment discontinuation recently failed to demonstrate the non-inferiority of treatment discontinuation over continuation, in terms of MRI activity. On the other hand, the evidence on the impact of discontinuation on disease progression is more conflicting and less robust. Furthermore, there is an important lack of studies concerning sequestering DMTs and virtually no data on the discontinuation of anti-CD20 monoclonal antibodies. De-escalation strategy is gaining attention as a de-risking approach alternative to complete treatment discontinuation. It may be defined as the decision to shift from HETs to less potent DMTs in elderly pwMS who have a stable disease. This strategy could reduce treatment-related risks, while minimizing the risk of disease activity and progression potentially associated with treatment discontinuation. This approach, however, remains unexplored due to a lack of studies. Given these findings, the present scenario underlines the urgent need for more comprehensive and robust studies to develop optimized, data-driven treatment strategies for elderly pwMS and LOMS, addressing the unique challenges of MS treatment and aging.
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Affiliation(s)
- Stefano Gelibter
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Lorenzo Saraceno
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fiammetta Pirro
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Emanuela Laura Susani
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alessandra Protti
- Department of Neurosciences, Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Fernández Ó, Sörensen PS, Comi G, Vermersch P, Hartung HP, Leocani L, Berger T, Van Wijmeersch B, Oreja-Guevara C. Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review. Front Immunol 2024; 15:1379538. [PMID: 38646534 PMCID: PMC11032020 DOI: 10.3389/fimmu.2024.1379538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/23/2024] Open
Abstract
Multiple Sclerosis (MS) management in individuals aged 55 and above presents unique challenges due to the complex interaction between aging, comorbidities, immunosenescence, and MS pathophysiology. This comprehensive review explores the evolving landscape of MS in older adults, including the increased incidence and prevalence of MS in this age group, the shift in disease phenotypes from relapsing-remitting to progressive forms, and the presence of multimorbidity and polypharmacy. We aim to provide an updated review of the available evidence of disease-modifying treatments (DMTs) in older patients, including the efficacy and safety of existing therapies, emerging treatments such as Bruton tyrosine kinase (BTKs) inhibitors and those targeting remyelination and neuroprotection, and the critical decisions surrounding the initiation, de-escalation, and discontinuation of DMTs. Non-pharmacologic approaches, including physical therapy, neuromodulation therapies, cognitive rehabilitation, and psychotherapy, are also examined for their role in holistic care. The importance of MS Care Units and advance care planning are explored as a cornerstone in providing patient-centric care, ensuring alignment with patient preferences in the disease trajectory. Finally, the review emphasizes the need for personalized management and continuous monitoring of MS patients, alongside advocating for inclusive study designs in clinical research to improve the management of this growing patient demographic.
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Affiliation(s)
- Óscar Fernández
- Departament of Pharmacology, Faculty of Medicine; Institute of Biomedical Research of Malaga (IBIMA), Regional University Hospital of Malaga, Malaga, Spain
- Department of Pharmacology and Pediatry, Faculty of Medicine, University of Malaga, Malaga, Spain
| | - Per Soelberg Sörensen
- Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Copenhagen and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Giancarlo Comi
- Department of Neurorehabilitation Sciences, Multiple Sclerosis Centre Casa di Cura Igea, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, Sydney, NSW, Australia
- Department of Neurology, Palacky University Olomouc, Olomouc, Czechia
| | - Letizia Leocani
- Department of Neurorehabilitation Sciences, Multiple Sclerosis Centre Casa di Cura Igea, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Thomas Berger
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Bart Van Wijmeersch
- University MS Centre, Hasselt-Pelt, Belgium
- Rehabilitation and Multiple Sclerosis (MS), Noorderhart Hospitals, Pelt, Belgium
| | - Celia Oreja-Guevara
- Department of Neurology, Hospital Clínico Universitario San Carlos, IdISSC, Madrid, Spain
- Department of Medicine, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Graf J, Ng HS, Zhu F, Zhao Y, Wijnands JMA, Evans C, Fisk JD, Marrie RA, Tremlett H. Disease-modifying drugs, multiple sclerosis and infection-related healthcare use in British Columbia, Canada: a population-based study. LANCET REGIONAL HEALTH. AMERICAS 2024; 29:100667. [PMID: 38269206 PMCID: PMC10806332 DOI: 10.1016/j.lana.2023.100667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024]
Abstract
Background Much remains unknown surrounding the disease-modifying drugs (DMDs) used to treat multiple sclerosis and infection-related healthcare use in the 'real-world' setting. We examined if DMD exposure was associated with altered infection-related healthcare use. Methods We assessed if DMD (versus no) exposure was associated with altered infection-related hospitalizations, physician claims, and prescriptions filled in British Columbia, Canada (1996-2017). Healthcare use was assessed using negative binomial and proportional means regression models, reported as sex-/age-/comorbidity-/calendar year-/socioeconomic-adjusted rate and hazard ratios [aRR, aHR], with 95% confidence intervals [CIs]). Findings We identified 19,360 multiple sclerosis cases (13,940/19,360; 72.0% women; mean age at study start = 44.5 standard deviation, SD = 13.3; mean follow-up = 11.7 [SD = 7.3] years). Relative to unexposed periods, exposure to any DMD was associated with a lower infection-related rate of physician claims (aRR = 0.88; 95% CI:0.85-0.92) and hazard of hospitalization (aHR = 0.64; 95% CI:0.56-0.73), and a higher rate of infection-related prescriptions (aRR = 1.14; 95% CI:1.08-1.20). Exposure to any injectable or oral DMD was associated with a lower infection-related rate of physician claims (injectable aRR = 0.88; 95% CI:0.84-0.92, oral aRR = 0.83; 95% CI:0.77-0.90) and hazard of hospitalization (injectable aHR = 0.65; 95% CI:0.56-0.75, oral aHR = 0.54; 95% CI:0.38-0.77), whereas intravenous DMD exposure was not (aRR = 0.99; 95% CI:0.86-1.14, aHR = 0.73; 95% CI:0.49-1.09). Exposure to any injectable or intravenous DMD was associated with a higher rate of infection-related prescriptions (injectable aRR = 1.15; 95% CI:1.08-1.22, intravenous = 1.34; 95% CI:1.15-1.56), whereas oral DMDs were not (aRR = 0.98; 95% CI:0.91-1.05). Interpretation DMD exposure for the treatment of MS was associated with differences in infection-related healthcare use. While infection-related hospitalizations and physician visits were lower, prescription fills were higher. How these differences in infection-related healthcare use affect outcomes in persons with multiple sclerosis warrants consideration. Funding Canadian Institutes of Health Research (CIHR); German Research Foundation (DFG).
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Affiliation(s)
- Jonas Graf
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Huah Shin Ng
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Feng Zhu
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Yinshan Zhao
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - José MA. Wijnands
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Charity Evans
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada
| | - John D. Fisk
- Nova Scotia Health Authority and the Departments of Psychiatry, Psychology and Neuroscience, and Medicine, Dalhousie University, Halifax, NS, Canada
| | - 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
| | - Helen Tremlett
- Department of Medicine, Division of Neurology and the Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Graf J, Ng HS, Zhu F, Zhao Y, Wijnands JMA, Evans C, Fisk JD, Marrie RA, Tremlett H. Multiple sclerosis disease-modifying drug use by immigrants: a real-world study. Sci Rep 2023; 13:21235. [PMID: 38040796 PMCID: PMC10692166 DOI: 10.1038/s41598-023-46313-7] [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: 02/01/2023] [Accepted: 10/30/2023] [Indexed: 12/03/2023] Open
Abstract
Little is known about disease-modifying drug (DMD) initiation by immigrants with multiple sclerosis (MS) in countries with universal health coverage. We assessed the association between immigration status and DMD use within 5-years after the first MS-related healthcare encounter. Using health administrative data, we identified MS cases in British Columbia (BC), Canada. The index date was the first MS-related healthcare encounter (MS/demyelinating disease-related diagnosis or DMD prescription filled), and ranged from 01/January/1996 to 31/December/2012. Those included were ≥ 18 years old, BC residents for ≥ 1-year pre- and ≥ 5-years post-index date. Persons becoming permanent residents 1985-2012 were defined as immigrants, all others were long-term residents. The association between immigration status and any DMD prescription filled within 5-years post-index date (with the latest study end date being 31/December/2017) was assessed using logistic regression, reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). We identified 8762 MS cases (522 were immigrants). Among immigrants of lower SES, odds of filling any DMD prescription were reduced, whereas they did not differ between immigrants and long-term residents across SES quintiles (aOR 0.96; 95%CI 0.78-1.19). Overall use (odds) of a first DMD within 5 years after the first MS-related encounter was associated with immigration status.
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Affiliation(s)
- Jonas Graf
- Division of Neurology, Department of Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Huah Shin Ng
- Division of Neurology, Department of Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Feng Zhu
- Division of Neurology, Department of Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Yinshan Zhao
- Division of Neurology, Department of Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - José M A Wijnands
- Division of Neurology, Department of Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Charity Evans
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada
| | - John D Fisk
- Departments of Psychiatry, Psychology and Neuroscience, and Medicine, Nova Scotia Health Authority, Dalhousie University, Halifax, NS, Canada
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Helen Tremlett
- Division of Neurology, Department of Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.
- Division of Neurology, Department of Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia Vancouver, Rm S126, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
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Marriott JJ, Ekuma O, Fransoo R, Marrie RA. Switching to second line MS disease-modifying therapies is associated with decreased relapse rate. Front Neurol 2023; 14:1243589. [PMID: 37745666 PMCID: PMC10511745 DOI: 10.3389/fneur.2023.1243589] [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: 06/21/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
Background and objectives While randomized, controlled trials (RCTs) are the gold standard for determining treatment efficacy, they do not capture the effectiveness of treatment during real-world use. We aimed to evaluate the association between demographics and multiple sclerosis (MS) disease-modifying therapy (DMT) exposure, including treatment adherence and switches between different DMTs, on the risk of subsequent MS relapse. Methods All persons with relapsing-onset MS (pwRMS) living in Manitoba between 1999 and 2014 were identified from provincial healthcare databases using a validated case definition. Use of DMTs was abstracted from the provincial drug database covering all residents of Manitoba, including use of any DMT, stopping/starting any DMT, switches between different DMTs and adherence as defined by cumulative medication possession ratios (CUMMPRs) of 50, 70, 80 and 90%. Time to first-treated relapse was used as the outcome of interest in logistic regression and Cox-proportional hazards regression models adjusting for demographic covariates including age and year of diagnosis, sex, socioeconomic status and number of medical comorbidities. Results 1780 pwRMS were identified, including 1,510 who were on DMT at some point in the study period. While total DMT exposure was not associated with the time to subsequent treated relapse, individuals who switched between more than 2 DMTs had higher post-switch rates of relapse. Switching to second-line DMTs was associated with a longer time to treated relapse in comparison to those who remained on a first-line DMT (HR 0.44; 95%CI: 0.32-0.62, p < 0.0001). Discussion Switching to high-efficacy DMTs reduces the rates of subsequent MS relapse at the population level.
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Affiliation(s)
- James John Marriott
- Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Okechukwu Ekuma
- Manitoba Centre for Health Policy, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Randall Fransoo
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ruth Ann Marrie
- Department of Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurology, Department of Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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Macaron G, Larochelle C, Arbour N, Galmard M, Girard JM, Prat A, Duquette P. Impact of aging on treatment considerations for multiple sclerosis patients. Front Neurol 2023; 14:1197212. [PMID: 37483447 PMCID: PMC10361071 DOI: 10.3389/fneur.2023.1197212] [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: 03/30/2023] [Accepted: 05/18/2023] [Indexed: 07/25/2023] Open
Abstract
With a rapidly aging global population and improvement of outcomes with newer multiple sclerosis (MS)-specific disease-modifying therapies (DMTs), the epidemiology of MS has shifted to an older than previously described population, with a peak prevalence of the disease seen in the 55-65 years age group. Changes in the pathophysiology of MS appear to be age-dependent. Several studies have identified a consistent phase of disability worsening around the fifth decade of life. The latter appears to be independent of prior disease duration and inflammatory activity and concomitant to pathological changes from acute focal active demyelination to chronic smoldering plaques, slow-expanding lesions, and compartmentalized inflammation within the central nervous system (CNS). On the other hand, decreased CNS tissue reserve and poorer remyelinating capacity with aging lead to loss of relapse recovery potential. Aging with MS may imply longer exposure to DMTs, although treatment efficacy in patients >55 years has not been evaluated in pivotal randomized controlled trials and appears to decrease with age. Older individuals are more prone to adverse effects of DMTs, an important aspect of treatment individualization. Aging with MS also implies a higher global burden of comorbid illnesses that contribute to overall impairments and represent a crucial confounder in interpreting clinical worsening. Discontinuation of DMTs after age 55, when no evidence of clinical or radiological activity is detected, is currently under the spotlight. In this review, we will discuss the impact of aging on MS pathobiology, the effect of comorbidities and other confounders on clinical worsening, and focus on current therapeutic considerations in this age group.
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Affiliation(s)
- Gabrielle Macaron
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Faculté de Médecine, Université Saint-Joseph de Beyrouth, Beirut, Lebanon
| | - Catherine Larochelle
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Nathalie Arbour
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Manon Galmard
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Jean Marc Girard
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Alexandre Prat
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
| | - Pierre Duquette
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
- Department of Neurosciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Neuroimmunology Research Laboratory, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
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