Effectiveness and safety of switching to teriflunomide in older patients with relapsing multiple sclerosis: A real-world retrospective multicenter analysis

BACKGROUND

The prevalence of multiple sclerosis (MS) in older people is increasing due to population aging and availability of effective disease-modifying therapies (DMTs). Treating older people with MS is complicated by age-related and MS-related comorbidities, immunologic effects of prior DMTs, and immunosenescence. Teriflunomide is a once-daily oral immunomodulator that has demonstrated efficacy and acceptable safety in clinical trials of adults with relapsing forms of MS (RMS). However, there are limited clinical trial and real-world data regarding teriflunomide use in people with MS aged >55 years. We analyzed real-world data to assess the effectiveness and safety of teriflunomide in older people with RMS who had switched to this agent from other DMTs.

METHODS

People with RMS (relapsing remitting and active secondary progressive MS) aged ≥55 years who had switched from other DMTs to teriflunomide (7 mg or 14 mg) for ≥1 year were identified retrospectively by chart review at four sites in the United States. Data were extracted from medical records from 1 year pre-index to 2 years post-index (index defined as the teriflunomide start date). Assessments of effectiveness included annualized relapse rate (ARR), Expanded Disability Status Scale (EDSS) score, and magnetic resonance imaging (MRI) outcomes. Assessments of safety included lymphocyte counts, infections, and malignancies. We examined the effectiveness outcomes and lymphocyte counts within sub-groups defined by age (55-64, ≥65 years), sex, MS type, and prior route of DMT administration (oral, injectable, infusible).

RESULTS

In total, 182 patients with RMS aged ≥55 years who switched from other DMTs to teriflunomide were identified (mean [SD] age: 62.5 [5.4] years). Mean ARR decreased from the start of teriflunomide treatment (mean [SD]: 0.43 [0.61]) to year 1 post-index (0.13 [0.65]) and year 2 post-index (0.05 [0.28]). Mean EDSS score remained unchanged from index (mean [SD]: 4.5 [1.8]) to 1 year post-treatment (4.5 [1.8]) and increased slightly at 2 years post-treatment (4.7 [1.7]). MRI scans from index and years 1 and 2 post-index compared with scans from the previous year indicated that most patients had stable or improved MRI outcomes at index (87.7%) and remained stable or improved at years 1 (96.0%) and 2 (93.6%). Lymphopenia decreased at years 1 (21.4%) and 2 post-index (14.8%, compared to index (23.5%). By 1 year post-index, fewer patients had grade 3 or 4 lymphopenia, and at 2 years post-index, there were no patients with grade 3 or 4 lymphopenia. Infection incidence was low (n = 40, 22.0%) and none were related to teriflunomide. The decreases in lymphopenia were driven by decreases among people who switched from a prior oral DMT; there were no notable differences in lymphopenia across the other sub-groups examined. ARR, EDSS score, and MRI outcomes across all sub-groups were similar to the results of the overall population.

CONCLUSION

Our multicenter, longitudinal, retrospective study demonstrated that patients with RMS aged 55 or older switching to teriflunomide from other DMTs had significantly improved ARR, stable disability, and stable or improved MRI over up to 2 years' follow up. Safety results were acceptable with fewer patients exhibiting lymphopenia at years 1 and 2 post-index.

Vitamin B(12) deficiency and incontinence: is there an association?

BACKGROUND

This study investigated the relationship between B(12) (cobalamin) levels and incontinence in older outpatients using secondary data analysis.

METHODS

Between 1991 and 1999, there were 929 patients (258 men and 671 women) for whom urinary incontinence (UI), fecal incontinence (FI), and B(12) were prospectively recorded. Covariates included race, gender, age, medications, Mini-Mental State Examination, modified illness rating, and instrumental activities of daily living (IADLs).

RESULTS

Some form of incontinence (UI or FI or both) was found in 41% of subjects, isolated UI in 34%, double incontinence (DI) in 12%, and isolated FI in 4%. Having UI increased the risk of also having FI (p <.0001). Serum B(12) levels of 300 pg/ml or less were not predictive of isolated UI or isolated FI. However, in logistic regression, DI was predicted by B(12) (odds ratio [OR] = 2.113, p =.0094), IADLs (OR = 0.810, p <.0001), cathartics/laxative use (OR = 1.902, p =.126), and diuretic use (OR = 2.226, p =.006). Considering isolated UI in women, higher IADLs reduced risk of UI (OR = 0.956, p =.002), while diuretics (OR = 1.481, p =.041) and antihistamines (OR = 1.909, p =.046) both increased risk of UI. In men, only use of anticonvulsant medications (OR = 4.529, p =.023) increased risk of isolated UI. Greater physical illness in both genders increased risk of isolated FI (OR = 1.204, p =.006).

CONCLUSIONS

These findings suggest that serum B(12) at levels of 300 pg/ml or less are not associated with isolated UI or isolated FI but may play a role in DI. A possible association of low B(12) levels with DI is intriguing because of the implications for treatment and prevention. More immediately, medication side effects should be considered when evaluating this problem.

Pharmacologic management of Alzheimer disease, Part II: Antioxidants, antihypertensives, and ergoloid derivatives

OBJECTIVE

To provide information about research evaluating antioxidants in Alzheimer disease (AD) and to discuss the potential role of beta-blockers, angiotensin-converting enzyme inhibitors, clonidine, guanfacine, nimodipine, and ergoloid derivatives in AD therapy.

DATA SOURCES

Studies, review articles, and editorials identified from MEDLINE searches (from 1989 to 1997) and bibliographies of identified articles.

STUDY SELECTION

Studies and review articles addressing antioxidant, antihypertensive, and ergoloid derivative pharmacotherapy research.

DATA EXTRACTION

Pertinent information was selected and the data synthesized into a review format.

DATA SYNTHESIS

AD is a progressive neuropsychiatric disorder of unknown etiology. Studies evaluating the possible association between a free radical mechanism in AD and the potential role of antioxidants are reviewed. Additionally, the role of beta-blockers, angiotensin-converting enzyme inhibitors, clonidine, guanfacine, nimodipine, and ergoloid derivatives in AD management are discussed.

CONCLUSIONS

Preliminary evidence suggests that antioxidants may have a protective effect against the development of AD. Additional prospective, double-blind, placebo-controlled studies are needed to determine the role of antioxidants in the prevention and management of AD. Understanding the role of antioxidants in AD may suggest alternative agents that have similar pharmacologic activity. Beta-blockers may be an option to control agitation in AD patients for whom anxiolytics or antipsychotics are ineffective or are contraindicated because of their adverse effect profiles. Other agents that may have a role in AD therapy include angiotensin-converting enzyme inhibitors, nimodipine, and ergoloid derivatives. Clonidine and guanfacine have thus far shown little promise in improving cognitive function in AD. Further prospective, double-blind, placebo-controlled trials will be necessary to elucidate the role of these agents in AD management.

L-deprenyl in the treatment of mild dementia of the Alzheimer type: results of a 15-month trial

OBJECTIVE

To examine the cognitive and behavioral effects of L-deprenyl in persons with mild dementia of the Alzheimer type (DAT) over a 15-month period.

DESIGN

A 15-month randomized, double-blind, placebo-controlled trial using a parallel-group design.

PARTICIPANTS

39 subjects with mild DAT (CDR 1) selected using NINCDS-ADRDA criteria.

OUTCOME MEASURES

A battery of neuropsychological tests and clinical rating scales.

RESULTS

The placebo and L-deprenyl subjects were similar at baseline on the clinical and neuropsychological tests. The total score on the Brief Psychiatric Rating Scale (BPRS) was significantly less after 15 months in subjects taking L-deprenyl. The only individual item of the BPRS which differed between groups was disorientation. There was no evidence of a L-deprenyl effect on any other clinical or neuropsychological measure after 2, 8, or 15 months.

CONCLUSION

L-deprenyl did appear to have a slight effect on a single measure of psychopathology, the BPRS. It did not have a measurable impact on any other measure of behavior or cognitive function over a 15-month period in this group of subjects with mild DAT and did not appear to slow the progression of the disease.

L-deprenyl in the treatment of mild dementia of the Alzheimer type: preliminary results

OBJECTIVE

To examine the short-term cognitive and behavioral effects of L-deprenyl in persons with mild dementia of the Alzheimer type (DAT) over a 2-month period.

DESIGN

A 15-month randomized, double-blind, placebo-controlled trial using a parallel-group design. This report deals with the first 2 months of the trial.

PARTICIPANTS

39 subjects with mild DAT (CDR 1) selected using NINCDS-ADRDA criteria.

MEASURES

A battery of neuropsychological tests and clinical rating scales.

RESULTS

The placebo and L-deprenyl subjects were similar at baseline on the clinical and neuropsychological tests. There was no evidence of a L-deprenyl effect on any clinical or neuropsychological measures after 2 months.

CONCLUSION

L-deprenyl did not have a measurable impact on behavior or cognitive function over a 2-month period in this group of subjects with mild DAT.