Multiple Sclerosis: A Global Concern with Multiple Challenges in an Era of Advanced Therapeutic Complex Molecules and Biological Medicines

Prevalence and incidence of multiple sclerosis in Bulgaria

Background

Multiple sclerosis (MS) is a chronic, inflammatory, autoimmune, demyelinating and neurodegenerative disease of the central nervous system that primarily affects young, active people and is a leading cause of non-traumatic, irreversible neurological deficit. Multiple sclerosis is one of the most studied diseases in neuroepidemiology and is characterized by an uneven geographical distribution worldwide.

Objective

To estimate the prevalence and incidence of multiple sclerosis in Bulgaria and their distribution by age and gender, using data from the latest population census in the country, provided by the National Statistical Institute.

Methods

An epidemiological study, covering a 7-year period-from 2015 to 2021 was conducted in Bulgaria. Eight regions with their population were included in the study-Blagoevgrad, Montana, Pernik, Svoge, Smolyan, Troyan, Haskovo and Shumen. Data, provided by the National Statistical Institute, were used to calculate the values of prevalence and incidence of multiple sclerosis. All cases were diagnosed using the 2017 McDonald's diagnostic criteria. The results obtained from the study were also used to determine the clinical characteristics of the Bulgarian patient. For the purposes of the epidemiological study an individual questionnaire was developed.

Results

On the prevalence day-07.09.2021, there were 532 people with multiple sclerosis in the studied regions of the country, revealing a prevalence of 121.2/100000 and an incidence of 4.2/100000. 182 of them were males and 350 were females comprising a ratio of 2:1 in favor of the women. More than 50% of all cases had relapsing-remitting course of disease. Secondary-progressive MS had 30% of all patients and 10% suffered from primary progressive multiple sclerosis. Clinically isolated syndrome was present in less than 5% of patients. The mean age at disease onset was 32.2 ± 10.3 years.

Conclusion

The established values of prevalence and incidence position Bulgaria in the area with a high frequency of MS. There is an increase in prevalence and incidence compared to previous studies conducted in the country. The results obtained are similar to those reported by the neighboring countries of the Balkan Peninsula and are close to the average values in Europe according to the latest edition of Atlas of Multiple Sclerosis.

Review of evidence linking exposure to environmental stressors and associated alterations in the dynamics of immunosenescence (ISC) with the global increase in multiple sclerosis (MS)

Historical survey confirms that, over the latter part of the 20th century, autoimmune-based diseases, including multiple sclerosis (MS), have shown a worldwide increase in incidence and prevalence. Analytical population studies have established that the exponential rise in MS is not solely due to improvements in diagnosis and healthcare but relates to an increase in autoimmune risk factors. Harmful environmental exposures, including non-communicable social determinants of health, anthropogens and indigenous or transmissible microbes, constitute a group of causal determinants that have been closely linked with the global rise in MS cases. Exposure to environmental stressors has profound effects on the adaptive arm of the immune system and, in particular, the associated intrinsic process of immune ageing or immunosenescence (ISC). Stressor-related disturbances to the dynamics of ISC include immune cell-linked untimely or premature (p) alterations and an accelerated replicative (ar) change. A recognised immune-associated feature of MS is pISC and current evidence supports the presence of an arISC during the disease. Moreover, collated data illustrates the immune-associated alterations that characterise pISC and arISC are inducible by environmental stressors strongly implicated in causing duplicate changes in adaptive immune cells during MS. The close relationship between exposure to environmental risk factors and the induction of pISC and arISC during MS offers a valid mechanism through which pro-immunosenescent stressors may act and contribute to the recorded increase in the global rate and number of new cases of the disease. Confirmation of alterations to the dynamics of ISC during MS provides a rational and valuable therapeutic target for the use of senolytic drugs to either prevent accumulation and enhance ablation of less efficient untimely senescent adaptive immune cells or decelerate the dysregulated process of replicative proliferation. A range of senotherapeutics are available including kinase and transcriptase inhibitors, rapalogs, flavanols and genetically-engineered T cells and the use of selective treatments to control emerging and unspecified aspects of pISC and arISC are discussed.

From Animal Models to Clinical Trials: The Potential of Antimicrobials in Multiple Sclerosis Treatment

Multiple sclerosis (MS) is a chronic, autoimmune, demyelinating disease of the central nervous system (CNS). Microbes, including bacteria and certain viruses, particularly Epstein-Barr virus (EBV), have been linked to the pathogenesis of MS. While there is currently no cure for MS, antibiotics and antivirals have been studied as potential treatment options due to their immunomodulatory ability that results in the regulation of the immune process. The current issue addressed in this systematic review is the effect of antimicrobials, including antibiotics, antivirals, and antiparasitic agents in animals and humans. We performed a comprehensive search of PubMed, Google Scholar, and Scopus for articles on antimicrobials in experimental autoimmune encephalomyelitis animal models of MS, as well as in people with MS (pwMS). In animal models, antibiotics tested included beta-lactams, minocycline, rapamycin, macrolides, and doxycycline. Antivirals included acyclovir, valacyclovir, and ganciclovir. Hydroxychloroquine was the only antiparasitic that was tested. In pwMS, we identified a total of 24 studies, 17 of them relevant to antibiotics, 6 to antivirals, and 1 relevant to antiparasitic hydroxychloroquine. While the effect of antimicrobials in animal models was promising, only minocycline and hydroxychloroquine improved outcome measures in pwMS. No favorable effect of the antivirals in humans has been observed yet. The number and size of clinical trials testing antimicrobials have been limited. Large, multicenter, well-designed studies are needed to further evaluate the effect of antimicrobials in MS.

A Systematic Review and Meta-Analysis of the Brief Cognitive Assessment for Multiple Sclerosis (BICAMS) International Validations

Cognitive impairment is a prevalent and debilitating symptom of multiple sclerosis (MS) but is not routinely addressed in clinical care. The Brief Cognitive Assessment for Multiple Sclerosis (BICAMS) was developed in 2012 to screen and monitor MS patients’ cognition. This systematic review and meta-analysis aimed to identify, synthesise, and critically appraise current BICAMS’ international validations. The literature search was conducted using PubMed, PsycINFO and Web of Science electronic databases in August 2022. Quantitative, peer-reviewed adult studies, which followed the BICAMS international validation protocol and were published in English, were included. The search identified a total of 203 studies, of which 26 were eligible for inclusion. These reported a total of 2833 adults with MS and 2382 healthy controls (HC). The meta-analysis showed that BICAMS identified impaired cognitive functioning in adults with MS compared to HC for all three subtests: information processing speed (g = 0.854, 95% CI = 0.765, 0.944, p < 0.001), immediate verbal recall (g = 0.566, 95% CI = 0.459, 0.673, p < 0.001) and immediate visual recall (g = 0.566, 95% CI = 0.487, 0.645, p < 0.001). Recruitment sites and strategies limit the generalisability of results. BICAMS is a valid and feasible international MS cognitive assessment.

Srivastava MV, Tripathi M, Srivastava A, Prasad K, Vibha D, Vishnu VY, Rajan R, Pandit A, Singh R, Gupta A, Elavarasi A, Das A, Divya MR, Ramanujam B, Agarwal A. Patients with neurological illnesses and their experience during the lockdown: A teleinterview-based study

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The current status and challenges in multiple sclerosis management in the Philippines

BACKGROUND

The provision of adequate services for individuals living with multiple sclerosis (MS) is an important issue since MS has a chronic and debilitating course.

OBJECTIVE

We aimed to review the literature on health service delivery for individuals with MS in the Philippines and identify the gaps in adequate provision of healthcare in these individuals.

METHODS

We reviewed data from relevant local and international repositories on health service delivery for individuals with MS in the Philippines.

RESULTS

The epidemiology of MS in the Philippine setting remains unknown. Approximately 1 neurologist caters to 175,000 Filipinos aged 15 and above, and nearly half are practicing in the National Capital Region. Physical access to magnetic resonance imaging is severely limited at 0.8 MRI unit per million Filipinos. Household out-of-pocket payment and voluntary health care payment schemes contributed 53.9% and 12.2%, respectively, to the current health expenditures. The average monthly income of a Filipino household is only 519 USD which may not be enough to cover treatment of a single relapse let alone costly disease-modifying treatments.

CONCLUSION

The Philippines faces challenges in terms of the availability of accurate epidemiologic information, resource allocation, access to services and provision of therapies for individuals with MS.

Circulating nucleic acids in the plasma and serum as potential biomarkers in neurological disorders

Neurological diseases are responsible for approximately 6.8 million deaths every year. They affect up to 1 billion people worldwide and cause significant disability and reduced quality of life. In most neurological disorders, the diagnosis can be challenging; it frequently requires long-term investigation. Thus, the discovery of better diagnostic methods to help in the accurate and fast diagnosis of neurological disorders is crucial. Circulating nucleic acids (CNAs) are defined as any type of DNA or RNA that is present in body biofluids. They can be found within extracellular vesicles or as cell-free DNA and RNA. Currently, CNAs are being explored as potential biomarkers for diseases because they can be obtained using non-invasive methods and may reflect unique characteristics of the biological processes involved in several diseases. CNAs can be especially useful as biomarkers for conditions that involve organs or structures that are difficult to assess, such as the central nervous system. This review presents a critical assessment of the most current literature about the use of plasma and serum CNAs as biomarkers for several aspects of neurological disorders: defining a diagnosis, establishing a prognosis, and monitoring the disease progression and response to therapy. We explored the biological origin, types, and general mechanisms involved in the generation of CNAs in physiological and pathological processes, with specific attention to neurological disorders. In addition, we present some of the future applications of CNAs as non-invasive biomarkers for these diseases.

An interpretative phenomenological analysis of dignity in people with multiple sclerosis

BACKGROUND

Dignity is a fundamental concept in healthcare. The symptoms of multiple sclerosis have a negative effect on dignity. Understanding of lived experience of dignity in people with multiple sclerosis is crucial to support dignity in practice.

RESEARCH AIM

The aim was to explore the sense of dignity experienced by people with multiple sclerosis.

RESEARCH DESIGN AND PARTICIPANTS

An interpretative phenomenological analysis design was adopted, using data collected through face-to-face interviews with 14 participants.

ETHICAL CONSIDERATIONS

The study was approved by the faculty Ethical Committee (No. EC 1828/2016).

FINDINGS

Four interconnected superordinate themes emerged from analysis: Loss of a fully-fledged life: Violating the dignity-of-self; To accept and fight: Promoting the dignity-of-self; Contempt and rudeness: Indignity-in-relation; and Those who know and see, help: Promoting dignity-in-relation. The loss of former fully-fledged life has a dramatic impact on integrity and impaired dignity-of-self. Accepting illness and changed identity impaired by multiple sclerosis was the step that the participants considered to be important for reacquiring the sense of dignity. The participants encountered misunderstandings, prejudices, embarrassment, insensitive remarks, labelling, unwillingness and impersonal treatment as indignities. Acceptance of their condition, needed support, the feeling of being part of a group, sensitivity and the sharing of problems had a positive effect on their dignity.

DISCUSSION

Continual changes in functional ability threaten an individual's identity and were experienced as violations of dignity. Based on this, participant's dignity-of-self was not a moral, but much more existential value. Acceptance of changed identity and fighting spirit were important for restoring their dignity-of-self. The misunderstandings, prejudices and unwillingness had a negative impact on their dignity-in-relation. On the other side, support from others in fighting promoted their dignity-in-relation.

CONCLUSION

Dignity is manifested as a complex phenomenon of lived experience of people with multiple sclerosis and also an umbrella concept for providing good quality of person-centred care.

Barriers to access and utilization of multiple sclerosis care services in a large cohort of Latin American patients

Background:

Multiple sclerosis (MS), is an emergent disease in Latin America (LATAM), which raises substantial socioeconomic challenges to a region where most countries remain as economies in development.

Objective:

To assess barriers to access and utilization of MS care services in a regional cohort survey.

Methods:

We conducted a cross-sectional study based on a self-reported survey. Patients with MS (PwMS) completed this regional survey in 12 Latin American (LATAM) countries. PwMS were also divided into those with healthcare insurance (including certain local national social security programs) and those without healthcare insurance (treated at public institutions).

Results:

We surveyed 1469 PwMS and identified significant regional differences in relation to access to complementary tests, rehabilitation services, and prescription of disease-modifying therapies (DMTs). Between 44.4% and 73.5% of PwMS were unemployed and nearly 50% had completed higher education. PwMS receiving care from the private sector reported greater access to imaging, DMTs, and fewer problems obtaining DMTs compared to those treated at public institutions. Multivariate analysis showed that lack of private insurance (OR = 2.21, p < 0.001), longer MS duration (OR = 1.02, p = 0.001), lower level of education (OR = 0.66, p = 0.009), and unemployment (OR = 0.73, p = 0.03) were independently associated with inappropriate delivery of DMTs.

Conclusion:

These findings suggest barriers to access and utilization of MS care services across LATAM are prevalent. We identified several factors predicting unmet healthcare needs in PwMS.

Biosimilar Drugs for Multiple Sclerosis: An Unmet International Need or a Regulatory Risk?

Multiple sclerosis (MS) more than any other neurological disorder has experienced a tremendous progress in available evidence-based innovator disease modifying therapies (DMT). These medications include injectable complex nonbiological drugs (CNBD), the injectable biological products β-interferons-1a and -1b, and the infusible monoclonal antibodies (MAB), as well as oral synthetic therapeutic molecules. The degree of efficacy and adverse effects profile is variable. By the end of 2019, all medications have been approved for relapsing forms of MS, including five with indication for clinically isolated syndrome (CIS), two for active secondary progressive MS, and one for primary progressive MS. With the advent of the first generation or "platform" injectable DMT in the 1990s the cost of MS care increased substantially driven basically by the cost of these therapies. As new drugs licensed by health agencies appeared in the global market, the cost of these agents notably increased augmenting the economic gravamen of disease particularly in North America This industrial phenomenon has been promoted by the remarkable profits obtained by the biopharmaceutical companies producing these medications, costs increasing about seven times per patient per year in the span of two decades. The global MS drug market was valued at US$16.3 billion in 2016, expecting to reach US$27.8 billion by 2025. The societal and economic effect of these costs constitute an international concern for health systems which adjudicate an increasing portion of financial resources to MS care. This effect has had a more notorious impact in emerging countries with economies in development. In the early 2000s the industry producers of biosimilar molecules initiated the concept of manufacturing follow-on biosimilar therapeutic options for MS available at a reduced cost without affecting efficacy and safety. Latin American biotechnological companies from Mexico, Argentina and Uruguay, introduced into the regional markets biosimilar β-interferons. These products were licensed by the local regulatory agencies without challenging pharmacological profile and their claims of similarity with the innovator medications. In the licensing process, biosimilar manufactures have typically utilized published literature and phase III clinical trials data previously acquired by the brand medication ("third approval pathway''). This has raised concerns among local neurological communities and patient organizations in the area. This situation is compounded by the fact that no discernible health cost savings have resulted since their introduction in Latin American countries. In some European countries where the health care system, public and private systems, regulated by Ministries of Health, negotiate with the pharmaceutical industry drug pricing and payment systems. The business scenario has stimulated local industries to produce follow-on biosimilar medications, theoretically to compete or replace the original brands. Countries such as Iran who have experienced a substantial increase in MS prevalence (101.19 per 100,000 inhabitants) has enabled their national Food and Drug Organization (FDO) to license locally produced biosimilar interferon 1-a and 1-b based on somewhat limited clinical studies. The Ministry of Health of the Russian Federation, approved the first biosimilar β-interferon-1a (44 mcg subcutaneous administration) manufactured in the country and developed in accordance to the guidelines of the European Medicine Agency (EMA) for phase I and phase III studies. The EMA, however, along with other international licensing agencies: United States Food and Drug Agency (FDA), Health Canada, the Japanese Pharmaceuticals and Medical Devices Agency (PMDA), the UK Medicines and Healthcare Products Regulatory Agency (MHPRA), and others, have produced strict guidelines regulating registration of biosimilar medicines. Thus far these agencies have not approved any interferon or MAB for MS based on these principles. The main obstacles for the approval of biosimilar medications by international health agencies is their consistent inability to demonstrate therapeutic equivalence through physiochemistry, biology, immunogenicity aspects, molecular behavior and clinical studies, preferably through a controlled phase III study, or ideally, utilizing a comparative head-to-head trial with the innovator. Recommendations proposed by experts from the Latin American region to guarantee production quality of biosimilar products, efficacy and safety, include strict application of current regulations; avoid uncontrolled interchangeability; implement strong pharmacovigilance; educate healthcare professionals and regulatory officials on the different issues involved in the biosimilarity concept and use evidence-based decision for therapy selection. The main priority should always be the protection and well-being of the patient irrespectively of therapy availability or pharmacoeconomic issues.

Living with a neglected neurological disease: a qualitative study of patients with multiple sclerosis in Malaysia

BACKGROUND

The needs of patients with multiple sclerosis have been well-studied in high-income, high-prevalence countries but few studies have been based in low- and middle-income countries where resources are relatively scarce. As such, little is known about the needs of patients living in these countries.

OBJECTIVE

The study seeks to develop an understanding of the needs of patients with multiple sclerosis living in Malaysia in order to generate insights and contribute to a global database of patients' experience.

METHOD

12 patients with multiple sclerosis participated in this qualitative study and took part in a semi-structured interview. The interviews were transcribed and analysed using an iterative thematic analysis approach.

RESULTS

The experiences, challenges and needs of the patients were reported. Five themes were developed (Daily living, Financial, Emotional and psychological, Healthcare, and Family). These predominantly revolved around the struggles of coping and adapting to the symptoms and disabilities imposed by multiple sclerosis, their heavy reliance on personal finances to cope with the increased costs of living for themselves and their families, as well as the limited healthcare services and treatments available to help them to manage the physical and emotional symptoms of multiple sclerosis.

CONCLUSION

Patients with multiple sclerosis in Malaysia have complex needs that are neglected due perceived lack of importance of the disease and the poor understanding of multiple sclerosis in general. Patients rely heavily on their finances to improve their quality of life. This perpetuates health inequities and reform of the national health financing system is needed to provide patients with the healthcare and support they need.Implications for rehabilitationPatients with multiple sclerosis in Malaysia prioritize being able to cope and adapt to their disabilities in order to continue performing their activities of daily living.There is a need to increase the availability and accessibility of healthcare professionals that are experienced with the management of multiple sclerosis.Healthcare professionals need to improve their understanding of the patients' needs and what they consider to be important in order to provide therapy that is effective and relevant.Patients also require financial support to help them with the increased costs of living associated with MS as well as the costs of healthcare services such as physiotherapy and rehabilitation.

Quantifying the Metabolic Signature of Multiple Sclerosis by in vivo Proton Magnetic Resonance Spectroscopy: Current Challenges and Future Outlook in the Translation From Proton Signal to Diagnostic Biomarker

Proton magnetic resonance spectroscopy (¹H-MRS) offers a growing variety of methods for querying potential diagnostic biomarkers of multiple sclerosis in living central nervous system tissue. For the past three decades, ¹H-MRS has enabled the acquisition of a rich dataset suggestive of numerous metabolic alterations in lesions, normal-appearing white matter, gray matter, and spinal cord of individuals with multiple sclerosis, but this body of information is not free of seeming internal contradiction. The use of ¹H-MRS signals as diagnostic biomarkers depends on reproducible and generalizable sensitivity and specificity to disease state that can be confounded by a multitude of influences, including experiment group classification and demographics; acquisition sequence; spectral quality and quantifiability; the contribution of macromolecules and lipids to the spectroscopic baseline; spectral quantification pipeline; voxel tissue and lesion composition; T₁ and T₂ relaxation; B₁ field characteristics; and other features of study design, spectral acquisition and processing, and metabolite quantification about which the experimenter may possess imperfect or incomplete information. The direct comparison of ¹H-MRS data from individuals with and without multiple sclerosis poses a special challenge in this regard, as several lines of evidence suggest that experimental cohorts may differ significantly in some of these parameters. We review the existing findings of in vivo¹H-MRS on central nervous system metabolic abnormalities in multiple sclerosis and its subtypes within the context of study design, spectral acquisition and processing, and metabolite quantification and offer an outlook on technical considerations, including the growing use of machine learning, by future investigations into diagnostic biomarkers of multiple sclerosis measurable by ¹H-MRS.