1
|
Lublin FD. Worsening MS-A reappraisal of how we characterize the MS disease course. Mult Scler 2023; 29:1699-1700. [PMID: 37850489 DOI: 10.1177/13524585231205973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Affiliation(s)
- Fred D Lublin
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
2
|
Koch MW, Moral E, Brieva L, Mostert J, Strijbis EMM, Comtois J, Repovic P, Bowen JD, Wolinsky JS, Lublin FD, Cutter G. Relapse recovery in relapsing-remitting multiple sclerosis: An analysis of the CombiRx dataset. Mult Scler 2023; 29:1776-1785. [PMID: 37830451 PMCID: PMC10687796 DOI: 10.1177/13524585231202320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/23/2023] [Accepted: 09/04/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Clinical relapses are the defining feature of relapsing forms of multiple sclerosis (MS), but relatively little is known about the time course of relapse recovery. OBJECTIVE The aim of this study was to investigate the time course of and patient factors associated with the speed and success of relapse recovery in people with relapsing-remitting MS (RRMS). METHODS Using data from CombiRx, a large RRMS trial (clinicaltrials.gov identifier NCT00211887), we measured the time to recovery from the first on-trial relapse. We used Kaplan-Meier survival analyses and Cox regression models to investigate the association of patient factors with the time to unconfirmed and confirmed relapse recovery. RESULTS CombiRx included 1008 participants. We investigated 240 relapses. Median time to relapse recovery was 111 days. Most recovery events took place within 1 year of relapse onset: 202 of 240 (84%) individuals recovered during follow-up, 161 of 202 (80%) by 180 days, and 189 of 202 (94%) by 365 days. Relapse severity was the only factor associated with relapse recovery. CONCLUSION Recovery from relapses takes place up to approximately 1 year after the event. Relapse severity, but no other patient factors, was associated with the speed of relapse recovery. Our findings inform clinical practice and trial design in RRMS.
Collapse
Affiliation(s)
- Marcus W Koch
- Departments of Clinical Neurosciences and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Ester Moral
- Department of Neurology, Hospital Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - Luis Brieva
- Neuroimmunology Group, Department of Medicine, University of Lleida-IRBLleida, Lleida, Spain Department of Neurology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Jop Mostert
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Eva MM Strijbis
- Department of Neurology, MS Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jacynthe Comtois
- Department of Medicine, Neurology Service, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada
| | - Pavle Repovic
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, WA, USA
| | - James D Bowen
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Jerry S Wolinsky
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Fred D Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
3
|
Thompson AJ, Moccia M, Amato MP, Calabresi PA, Finlayson M, Hawton A, Lublin FD, Marrie RA, Montalban X, Panzara M, Sormani MP, Strum J, Vickrey BG, Coetzee T. Do the current MS clinical course descriptors need to change and if so how? A survey of the MS community. Mult Scler 2023; 29:1363-1372. [PMID: 37691493 PMCID: PMC10580678 DOI: 10.1177/13524585231196786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/27/2023] [Accepted: 07/29/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND AND OBJECTIVES The current clinical course descriptors of multiple sclerosis (MS) include a combination of clinical and magnetic resonance imaging (MRI) features. Recently there has been a growing call to base these descriptors more firmly on biological mechanisms. We investigated the implications of proposing a new mechanism-driven framework for describing MS. METHODS In a web-based survey, multiple stakeholders rated the need to change current MS clinical course descriptors, the definitions of disease course and their value in clinical practice and related topics. RESULTS We received 502 responses across 49 countries. In all, 77% of the survey respondents supported changing the current MS clinical course descriptors. They preferred a framework that informs treatment decisions, aids the design and conduct of clinical trials, allows patients to understand their disease, and links disease mechanisms and clinical expression of disease. Clinical validation before dissemination and ease of communication to patients were rated as the most important aspects to consider when developing any new framework for describing MS. CONCLUSION A majority of MS stakeholders agreed that the current MS clinical course descriptors need to change. Any change process will need to engage a wide range of affected stakeholders and be guided by foundational principles.
Collapse
Affiliation(s)
- Alan J Thompson
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, NIHR University College London Hospitals Biomedical Research Centre, Faculty of Brain Sciences, University College London, London, UK
| | - Marcello Moccia
- Department of Molecular Biology and Molecular Biotechnology, Federico II University of Naples, Naples, Italy Multiple Sclerosis Unit, Policlinico Federico II University Hospital, Naples, Italy
| | - Maria Pia Amato
- Department NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Peter A Calabresi
- Department of Neurology and The Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marcia Finlayson
- School of Rehabilitation Therapy, Queens University, Kingston, ON, Canada
| | - Annie Hawton
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Fred D Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruth Ann Marrie
- Departments of Medicine & Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Xavier Montalban
- Multiple Sclerosis Centre of Catalonia and Department of Neurology-Neuroimmunology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Maria Pia Sormani
- Department of Health Sciences, University of Genoa, Genoa, Italy IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Barbara G Vickrey
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy Coetzee
- National Multiple Sclerosis Society, 733 Third Avenue, New York, NY 10017, USA
- National Multiple Sclerosis Society, New York, NY, USA
| |
Collapse
|
4
|
Lublin FD, Krieger SC. MS becomes a treatable disease: 30 years later. Mult Scler 2023:13524585231174781. [PMID: 37232509 DOI: 10.1177/13524585231174781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
30 years ago the first disease-modifying therapy for relapsing multiple sclerosis was approved for use in the United States and soon thereafter across the globe. Since then the field of MS therapeutics, and studies of immunopathogenesis and genetics, have advanced our understanding of the disease and raised the hope of better addressing the next challenges of treating progressive disease, enhancing repair of the damaged nervous system and, hopefully, of a cure. Thirty years into the MS treatment era, the field continues to debate fundamental aspects of MS, and there exists a widening chasm between the triumphs in relapsing disease and the desolation of MS progression, which remains the principal unmet need. In this Personal Viewpoint, we outline lessons learned from the first era of great therapeutic development, as we look to the future of MS research and therapeutics.
Collapse
Affiliation(s)
- Fred D Lublin
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis and Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephen C Krieger
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis and Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
5
|
Hua LH, Bar-Or A, Cohan SL, Lublin FD, Coyle PK, Cree BA, Meng X, Su W, Cox GM, Fox RJ. Effects of baseline age and disease duration on the efficacy and safety of siponimod in patients with active SPMS: Post hoc analyses from the EXPAND study. Mult Scler Relat Disord 2023; 75:104766. [PMID: 37245350 DOI: 10.1016/j.msard.2023.104766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Older age and longer disease duration (DD) may impact the effectiveness of disease-modifying therapies in patients with multiple sclerosis (MS). Siponimod is a sphingosine 1-phosphate receptor modulator approved for the treatment of active secondary progressive MS (SPMS) in many countries. The pivotal phase 3 EXPAND study examined siponimod versus placebo in a broad SPMS population with both active and non-active disease. In this population, siponimod demonstrated significant efficacy, including a reduction in the risk of 3-month confirmed disability progression (3mCDP) and 6-month confirmed disability progression (6mCDP). Benefits of siponimod were also observed across age and DD subgroups in the overall EXPAND population. Herein we sought to assess the clinical impact of siponimod across age and disease duration subgroups, specifically in participants with active SPMS. METHODS This study is a post hoc analysis of a subgroup of EXPAND participants with active SPMS (≥ 1 relapse in the 2 years before the study and/or ≥ 1 T1 gadolinium-enhancing magnetic resonance imaging lesion at baseline) receiving oral siponimod (2 mg/day) or placebo during EXPAND. Data were analyzed for participant subgroups stratified by age at baseline (primary cut-off: < 45 year ≥ 45 years; and secondary cut-off: < 50 years or ≥ 50 years) and by DD at baseline (< 16 years or ≥ 16 years). Efficacy endpoints were 3mCDP and 6mCDP. Safety assessments included adverse events (AEs), serious AEs, and AEs leading to treatment discontinuation. RESULTS Data from 779 participants with active SPMS were analyzed. All age and DD subgroups had 31-38% (3mCDP) and 27-43% (6mCDP) risk reductions with siponimod versus placebo. Compared with placebo, siponimod significantly reduced the risk of 3mCDP in participants aged ≥ 45 years (hazard ratio [HR]: 0.68; 95% confidence interval [CI]: 0.48-0.97), < 50 years (HR: 0.69; 95% CI: 0.49-0.98), ≥ 50 years (HR: 0.62; 95% CI: 0.40-0.96), and in participants with < 16 years DD (HR: 0.68; 95% CI: 0.47-0.98). The risk of 6mCDP was significantly reduced with siponimod versus placebo for participants aged < 45 years (HR: 0.60; 95% CI: 0.38-0.96), ≥ 45 years (HR: 0.67; 95% CI: 0.45-0.99), < 50 years (HR: 0.62; 95% CI: 0.43-0.90), and in participants with < 16 years DD (HR: 0.57; 95% CI: 0.38-0.87). Increasing age or longer MS duration did not appear to increase the risk of AEs, with an observed safety profile that remained consistent with the overall active SPMS and overall SPMS populations in EXPAND. CONCLUSIONS In participants with active SPMS, treatment with siponimod demonstrated a statistically significant reduction in the risk of 3mCDP and 6mCDP compared with placebo. Although not every outcome reached statistical significance in the subgroup analyses (possibly a consequence of small sample sizes), benefits of siponimod were seen across a spectrum of ages and DD. Siponimod was generally well tolerated by participants with active SPMS, regardless of baseline age and DD, and AE profiles were broadly similar to those observed in the overall EXPAND population.
Collapse
Affiliation(s)
- Le H Hua
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA.
| | - Amit Bar-Or
- Department of Neurology and the Center for Neuroinflammation and Experimental Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stanley L Cohan
- Providence Multiple Sclerosis Center, Providence Brain and Spine Institute, Portland, OR, USA
| | - Fred D Lublin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patricia K Coyle
- Department of Neurology, Stony Brook University, Stony Brook, NY, USA
| | - Bruce Ac Cree
- UCSF, Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Xiangyi Meng
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Wendy Su
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Robert J Fox
- Mellen Center for Multiple Sclerosis Treatment and Research Neurological Institute Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
6
|
Cutter G, Rudick RA, de Moor C, Singh CM, Fisher E, Koster T, Lublin FD, Wolinsky JS, McFarland H, Jacobson S, Naylor ML. Serum neurofilament light-chain levels and long-term treatment outcomes in relapsing-remitting multiple sclerosis patients: A post hoc analysis of the randomized CombiRx trial. Mult Scler J Exp Transl Clin 2023; 9:20552173231169463. [PMID: 37139460 PMCID: PMC10150429 DOI: 10.1177/20552173231169463] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/27/2023] [Indexed: 05/05/2023] Open
Abstract
Background CombiRx was a randomized, double-blind, placebo-controlled phase 3 trial in treatment-naive relapsing-remitting multiple sclerosis (RRMS) patients randomized to intramuscular interferon beta-1a (IM IFN beta-1a), glatiramer acetate (GA), or both therapies. Objective This analysis investigated changes in serum neurofilament light-chain (sNfL) levels in response to treatment and assessed baseline sNfL as a predictor of relapse. Methods RRMS patients treated with IM IFN beta-1a 30 µg weekly + placebo (n = 159), GA 20 mg/mL daily + placebo (n = 172), or IM IFN beta-1a + GA (n = 344) were included. A linear mixed model compared sNfL values over time. Cox regression models analyzed baseline sNfL and gadolinium-enhancing (Gd+) lesions as predictors of relapse. Results In all treatment arms, the proportion of patients with sNfL ≥16 pg/mL decreased significantly from baseline to 6 months and was maintained at 36 months. A significantly higher percentage of patients with both baseline sNfL ≥16 pg/mL and ≥1 Gd+ lesion experienced relapses within 90 days compared to patients with sNfL <16 pg/mL and/or no Gd+ lesions. Conclusion sNfL levels were reduced within 6 months and remained low at 36 months. Results suggest that the combination of lesion activity and sNfL was a stronger predictor of relapse than either factor alone.
Collapse
Affiliation(s)
- Gary Cutter
- Gary Cutter, Department of Biostatistics,
The University of Alabama at Birmingham, 1665 University Boulevard, Birmingham,
AL 35233, USA.
| | - Richard A Rudick
- Department of Neurology, Biogen Inc, Cambridge, MA, USA, at the time of these analyses
| | - Carl de Moor
- Biostatistics, Biogen Inc, Cambridge, MA, USA, at the time of these analyses
| | - Carol M Singh
- Biogen Digital Health, Biogen Inc, Cambridge, MA, USA
| | - Elizabeth Fisher
- Value Based Medicine, Biogen Inc, Cambridge, MA, USA, at the time of these analyses
| | - Thijs Koster
- Global Medical, Biogen Inc, Cambridge, MA, USA, at the time of these analyses
| | - Fred D Lublin
- Department of Neurology, Corinne Goldsmith
Dickinson Center for Multiple Sclerosis, New York, NY, USA and Friedman
Brain Institute, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Jerry S Wolinsky
- McGovern Medical School, The University of
Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Henry McFarland
- National Institute of Neurological Disorders
and Stroke, National Institutes of
Health, Bethesda, MD, USA
| | - Steven Jacobson
- Viral Immunology Section, National Institute
of Neurological Disorders and Stroke, National Institutes of
Health, Bethesda, MD, USA
| | - Maria L Naylor
- Global Medical, Biogen Inc, Cambridge, MA, USA, at the time of these analyses
| |
Collapse
|
7
|
Cohen JA, Lublin FD, Lock C, Pelletier D, Chitnis T, Mehra M, Gothelf Y, Aricha R, Lindborg S, Lebovits C, Levy Y, Motamed Khorasani A, Kern R. Evaluation of neurotrophic factor secreting mesenchymal stem cells in progressive multiple sclerosis. Mult Scler 2023; 29:92-106. [PMID: 36113170 PMCID: PMC9896300 DOI: 10.1177/13524585221122156] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Autologous mesenchymal stem cell neurotrophic factor-secreting cells (NurOwn®) have the potential to modify underlying disease mechanisms in progressive multiple sclerosis (PMS). OBJECTIVE This open-label phase II study was conducted to evaluate safety/efficacy of three intrathecal cell treatments. METHODS Eighteen participants with non-relapsing PMS were treated. The primary endpoint was safety. Secondary endpoints included: cerebrospinal fluid (CSF) biomarkers; timed 25-foot walk speed, nine-hole peg test (9-HPT), low-contrast letter acuity, symbol digit modalities test, and 12-item multiple sclerosis (MS) walking scale. Seventeen participants received all treatments. RESULTS No deaths/adverse events related to worsening of MS, clinical/magnetic resonance imaging (MRI) evidence of disease activation, and clinically significant changes in safety lab results were reported. Two participants developed symptoms of low back and leg pain, consistent with a diagnosis of arachnoiditis, occurring in one of three intrathecal treatments in both participants. Nineteen percent of treated participants achieved pre-specified ⩾ 25% improvements in timed 25-foot walk speed/nine-HPT at 28 weeks compared to baseline, along with consistent efficacy signals for pre-specified response criteria across other secondary efficacy outcomes. CSF neuroprotective factors increased, and inflammatory biomarkers decreased after treatment, consistent with the proposed mechanism of action. CONCLUSION Based on these encouraging preliminary findings, further confirmation in a randomized study is warranted.
Collapse
Affiliation(s)
- Jeffrey A Cohen
- JA Cohen Department of Neurology, Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Fred D Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christoper Lock
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Daniel Pelletier
- Department of Neurology, University of Southern California, Los Angeles, CA, USA
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Munish Mehra
- Department of Statistics, Tigermed, Somerset, NJ, USA
| | - Yael Gothelf
- Department of Research & Development, Brainstorm Cell Therapeutics, New York, NY, USA
| | - Revital Aricha
- Department of Research & Development, Brainstorm Cell Therapeutics, New York, NY, USA
| | - Stacy Lindborg
- Department of Research & Development, Brainstorm Cell Therapeutics, New York, NY, USA
| | - Chaim Lebovits
- Department of Research & Development, Brainstorm Cell Therapeutics, New York, NY, USA
| | - Yossef Levy
- Department of Research & Development, Brainstorm Cell Therapeutics, New York, NY, USA
| | - Afsaneh Motamed Khorasani
- Department of Research & Development, Brainstorm Cell Therapeutics, New York, NY, USA
- Department of Medical Affairs, Eonian Stanzas LLC, Potomac, MD, USA
| | - Ralph Kern
- Department of Research & Development, Brainstorm Cell Therapeutics, New York, NY, USA
| |
Collapse
|
8
|
Solomon AJ, Arrambide G, Brownlee W, Cross AH, Gaitan MI, Lublin FD, Makhani N, Mowry EM, Reich DS, Rovira À, Weinshenker BG, Cohen JA. Confirming a Historical Diagnosis of Multiple Sclerosis: Challenges and Recommendations. Neurol Clin Pract 2022; 12:263-269. [PMID: 35747540 PMCID: PMC9208427 DOI: 10.1212/cpj.0000000000001149] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/14/2021] [Indexed: 11/15/2022]
Abstract
Patients with a historical diagnosis of multiple sclerosis (MS)-a patient presenting with a diagnosis of MS made previously and by a different clinician-present specific diagnostic and therapeutic challenges in clinical practice. Application of the McDonald criteria is most straightforward when applied contemporaneously with a syndrome typical of an MS attack or relapse; however, retrospective application of the criteria in some patients with a historical diagnosis of MS can be problematic. Limited patient recollection of symptoms and evolution of neurologic examination and MRI findings complicate confirmation of an earlier MS diagnosis and assessment of subsequent disease activity or clinical progression. Adequate records for review of prior clinical examinations, laboratory results, and/or MRI scans obtained at the time of diagnosis or during ensuing care may be inadequate or unavailable. This article provides recommendations for a clinical approach to the evaluation of patients with a historical diagnosis of MS to aid diagnostic confirmation, avoid misdiagnosis, and inform therapeutic decision making.
Collapse
Affiliation(s)
- Andrew J Solomon
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Georgina Arrambide
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Wallace Brownlee
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Anne H Cross
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - María I Gaitan
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Fred D Lublin
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Naila Makhani
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Ellen M Mowry
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Daniel S Reich
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Àlex Rovira
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Brian G Weinshenker
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Jeffrey A Cohen
- Department of Neurological Sciences (AJS), Larner College of Medicine at the University of Vermont, University Health Center - Arnold 2, Burlington, VT; Servei de Neurologia-Neuroimmunologia (GA), Centre d'Esclerosi Múltiple de Catalunya, (Cemcat), Vall d'Hebron Institut de Recerca, Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain; National Hospital for Neurology and Neurosurgery (WB), London, United Kingdom; Department of Neurology (AHC), Washington University School of Medicine, St. Louis, MO; Department of Neurology (MIG), Neuroimmunology Section, FLENI, Buenos Aires City, Argentina; The Corinne Goldsmith Dickinson Center for Multiple Sclerosis (FDL), Icahn School of Medicine at Mount Sinai, New York, NY; Departments of Pediatrics and Neurology (NM), Yale School of Medicine, New Haven, CT; Multiple Sclerosis Precision Medicine Center of Excellence (EMM), Johns Hopkins University, Baltimore, MD; Translational Neuroradiology Section (DSR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; Section of Neuroradiology (ÀR), Department of Radiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Department of Neurology (BGW), Mayo Clinic, Rochester, MN; and Mellen Center for MS Treatment and Research (JAC), Neurological Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
9
|
Comi G, Dadon Y, Sasson N, Steinerman JR, Knappertz V, Vollmer TL, Boyko A, Vermersch P, Ziemssen T, Montalban X, Lublin FD, Rocca MA, Volkinshtein R, Rubinchick S, Halevy N, Filippi M. CONCERTO: A randomized, placebo-controlled trial of oral laquinimod in relapsing-remitting multiple sclerosis. Mult Scler 2022; 28:608-619. [PMID: 34378456 DOI: 10.1177/13524585211032803] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Interventions targeting the adaptive immune response are needed in multiple sclerosis (MS). OBJECTIVE Evaluate laquinimod's efficacy, safety, and tolerability in patients with relapsing-remitting multiple sclerosis (RRMS). METHODS CONCERTO was a randomized, double-blind, placebo-controlled, phase-3 study. RRMS patients were randomized 1:1:1 to receive once-daily oral laquinimod 0.6 or 1.2 mg or placebo for ⩽24 months (n = 727, n = 732, and n = 740, respectively). Primary endpoint was time to 3-month confirmed disability progression (CDP). The laquinimod 1.2-mg dose arm was discontinued (1 January 2016) due to cardiovascular events at high doses. Safety was monitored throughout the study. RESULTS CONCERTO did not meet the primary endpoint of significant effect with laquinimod 0.6-mg versus placebo on 3-month CDP (hazard ratio: 0.94; 95% confidence interval: 0.67-1.31; p = 0.706). Secondary endpoint p values were nominal and non-inferential. Laquinimod 0.6 mg demonstrated 40% reduction in percent brain volume change from baseline to Month 15 versus placebo (p < 0.0001). The other secondary endpoint, time to first relapse, and annualized relapse rate (an exploratory endpoint) were numerically lower (both, p = 0.0001). No unexpected safety findings were reported with laquinimod 0.6 mg. CONCLUSION Laquinimod 0.6 mg demonstrated only nominally significant effects on clinical relapses and magnetic resonance imaging (MRI) outcomes and was generally well tolerated. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT01707992).
Collapse
Affiliation(s)
- Giancarlo Comi
- Vita-Salute San Raffaele University, Milan, Italy/Centro Sclerosi Multipla, Presidio Ospedaliero di Gallarate, Gallarate, Italy
| | - Yuval Dadon
- Teva Pharmaceutical Industries, Netanya, Israel
| | | | | | | | | | - Alexey Boyko
- Pirogov Russian National Research University and Department of Neuroimmunology of the Federal Center of Cerebrovascular Pathology and Stroke, Moscow, Russia
| | - Patrick Vermersch
- Univ. Lille, Inserm U1172 LilNCog, CHU Lille, FHU Precise, Lille, France
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital, Dresden, Germany
| | - Xavier Montalban
- Division of Neurology, St Michael's Hospital, University of Toronto, Toronto, ON, Canada/Department of Neurology-Neuroimmunology, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Fred D Lublin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria A Rocca
- Vita-Salute San Raffaele University, Milan, Italy/Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy/Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | | | - Massimo Filippi
- Vita-Salute San Raffaele University, Milan, Italy/Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy/Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy/Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy/Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| |
Collapse
|
10
|
Lublin FD, Häring DA, Ganjgahi H, Ocampo A, Hatami F, Čuklina J, Aarden P, Dahlke F, Arnold DL, Wiendl H, Chitnis T, Nichols TE, Kieseier BC, Bermel RA. OUP accepted manuscript. Brain 2022; 145:3147-3161. [PMID: 35104840 PMCID: PMC9536294 DOI: 10.1093/brain/awac016] [Citation(s) in RCA: 103] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/01/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
Patients with multiple sclerosis acquire disability either through relapse-associated worsening (RAW) or progression independent of relapse activity (PIRA). This study addresses the relative contribution of relapses to disability worsening over the course of the disease, how early progression begins and the extent to which multiple sclerosis therapies delay disability accumulation. Using the Novartis-Oxford multiple sclerosis (NO.MS) data pool spanning all multiple sclerosis phenotypes and paediatric multiple sclerosis, we evaluated ∼200 000 Expanded Disability Status Scale (EDSS) transitions from >27 000 patients with ≤15 years follow-up. We analysed three datasets: (i) A full analysis dataset containing all observational and randomized controlled clinical trials in which disability and relapses were assessed (n = 27 328); (ii) all phase 3 clinical trials (n = 8346); and (iii) all placebo-controlled phase 3 clinical trials (n = 4970). We determined the relative importance of RAW and PIRA, investigated the role of relapses on all-cause disability worsening using Andersen-Gill models and observed the impact of the mechanism of worsening and disease-modifying therapies on the time to reach milestone disability levels using time continuous Markov models. PIRA started early in the disease process, occurred in all phenotypes and became the principal driver of disability accumulation in the progressive phase of the disease. Relapses significantly increased the hazard of all-cause disability worsening events; following a year in which relapses occurred (versus a year without relapses), the hazard increased by 31–48% (all P < 0.001). Pre-existing disability and older age were the principal risk factors for incomplete relapse recovery. For placebo-treated patients with minimal disability (EDSS 1), it took 8.95 years until increased limitation in walking ability (EDSS 4) and 18.48 years to require walking assistance (EDSS 6). Treating patients with disease-modifying therapies delayed these times significantly by 3.51 years (95% confidence limit: 3.19, 3.96) and 3.09 years (2.60, 3.72), respectively. In patients with relapsing-remitting multiple sclerosis, those who worsened exclusively due to RAW events took a similar length of time to reach milestone EDSS values compared with those with PIRA events; the fastest transitions were observed in patients with PIRA and superimposed relapses. Our data confirm that relapses contribute to the accumulation of disability, primarily early in multiple sclerosis. PIRA begins in relapsing-remitting multiple sclerosis and becomes the dominant driver of disability accumulation as the disease evolves. Pre-existing disability and older age are the principal risk factors for further disability accumulation. The use of disease-modifying therapies delays disability accrual by years, with the potential to gain time being highest in the earliest stages of multiple sclerosis.
Collapse
Affiliation(s)
- Fred D Lublin
- Correspondence to: Professor Fred D. Lublin The Corinne Goldsmith Dickinson Center for Multiple Sclerosis Icahn School of Medicine at Mount Sinai 5 East 98th Street, Box 1138 New York, NY 10029-6574, USA E-mail:
| | | | - Habib Ganjgahi
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Farhad Hatami
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | | | | | - Douglas L Arnold
- McConnell Brain Imaging Centre, Montreal Neurological Institute and Hospital, McGill University, Montréal, QC, Canada
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Thomas E Nichols
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Robert A Bermel
- Department of Neurology, Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
11
|
Koch MW, Mostert J, Repovic P, Bowen JD, Wolinsky JS, Lublin FD, Strijbis E, Cutter G. Early first-line treatment response and subsequent disability worsening in relapsing-remitting multiple sclerosis. Eur J Neurol 2021; 29:1106-1116. [PMID: 34927308 DOI: 10.1111/ene.15220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/13/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Treatment success in relapsing-remitting multiple sclerosis (RRMS) is generally determined using relapse frequency and magnetic resonance imaging (MRI) activity in the first 6 or 12 months on treatment. The association of these definitions of short-term treatment success with disability worsening and disease activity in the longer term is unclear. In this study, we investigated risk factors associated with early first-line treatment failure in RRMS, and the association of early treatment failure with subsequent disability worsening or "no evidence of disease activity" (NEDA-3) status. METHODS We used data from CombiRx (clinicaltrials.gov identifier NCT00211887) to investigate risk factors associated with early treatment failure, and the association of early treatment failure at 6 and 12 months with subsequent disability worsening or NEDA-3 at 36 months. RESULTS CombiRx included 1008 treatment-naïve participants with RRMS, who were randomly assigned to treatment with glatiramer acetate, interferon beta, or the combination of both. Early treatment failure at 6 or 12 months by several definitions was associated with NEDA-3 failure at 36 months, but not with subsequent disability worsening at 36 months. Expanded Disability Status Scale (EDSS) was the only baseline characteristic associated with the risk of disability worsening at 36 months. Approximately 70% of NEDA-3 failures occurred due to MRI activity, and <10% occurred due to EDSS worsening. CONCLUSIONS Our investigation shows that current definitions of early treatment failure in RRMS are unrelated to patient-relevant disability worsening at 36 months of follow-up. Further research into useful definitions of treatment success and failure in RRMS is needed.
Collapse
Affiliation(s)
- Marcus W Koch
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jop Mostert
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Pavle Repovic
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - James D Bowen
- Multiple Sclerosis Center, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Jerry S Wolinsky
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Fred D Lublin
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eva Strijbis
- Department of Neurology, MS Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
12
|
Koch MW, Mostert JP, Wolinsky JS, Lublin FD, Uitdehaag B, Cutter GR. Comparison of the EDSS, Timed 25-Foot Walk, and the 9-Hole Peg Test as Clinical Trial Outcomes in Relapsing-Remitting Multiple Sclerosis. Neurology 2021; 97:e1560-e1570. [PMID: 34433679 DOI: 10.1212/wnl.0000000000012690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/16/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Clinical trials in relapsing-remitting multiple sclerosis (RRMS) usually use the Expanded Disability Status Scale (EDSS) as their primary disability outcome measure, while the more recently developed outcomes timed 25-ft walk (T25FW) and 9-hole peg test (NHPT) may be more useful and patient relevant. The objective of this work was to compare the EDSS to the T25FW and NHPT in a large RRMS randomized controlled trial (RCT) dataset. METHODS We used the dataset from Combination Therapy in Patients With Relapsing-Remitting Multiple Sclerosis (CombiRx) (clinicaltrials.gov identifier NCT00211887), a large phase 3 RCT, to compare the EDSS to the alternative outcomes T25FW and NHPT. We investigated disability worsening vs similarly defined improvement, unconfirmed vs confirmed and sustained disability change, and the presentation methods cumulative Kaplan-Meier survival curves vs cross-sectional disability worsening. RESULTS CombiRx included 1,008 participants. A comparison of confirmed and sustained worsening events showed that, throughout the trial, there were substantially fewer sustained than confirmed events, with a positive predictive value of confirmed for sustained worsening at 24 months of 0.73 for the EDSS, 0.73 for the T25FW, and 0.8 for the NHPT. More concerning were the findings that worsening on the EDSS occurred as frequently as similarly defined improvement throughout the 3 years of follow-up and that improvement rates increased in parallel with worsening rates. The T25FW showed low improvement rates of <10% throughout the trial. We also found that Kaplan-Meier survival analysis, the standard presentation and analysis method in modern RRMS trials, yields exaggerated estimates of disability worsening. With the Kaplan-Meier method, the proportion of patients with worsening events steadily increases until it reaches several-fold the number of events seen with more conservative analysis methods. For 3-month confirmed disability worsening up to 36 months, the Kaplan-Meier method yields 2.6-fold higher estimates for the EDSS, 2.9-fold higher estimates for the T25FW, and 5.1-fold higher estimates for the NHPT compared to a more conservative presentation of the same data. DISCUSSION Our analyses raise concerns about using the EDSS as the standard disability outcome in RRMS trials and suggest that the T25FW may be a more useful measure. These findings are relevant for the design and critical appraisal of RCTs.
Collapse
Affiliation(s)
- Marcus W Koch
- From the Departments of Clinical Neurosciences (M.W.K.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; Department of Neurology (J.P.M.), Rijnstate Hospital, Arnhem, the Netherlands; Department of Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth); Corinne Goldsmith Dickinson Center for MS (F.D.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (B.U.), MS Center Amsterdam, Amsterdam University Medical Centers, the Netherlands; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham.
| | - Jop P Mostert
- From the Departments of Clinical Neurosciences (M.W.K.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; Department of Neurology (J.P.M.), Rijnstate Hospital, Arnhem, the Netherlands; Department of Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth); Corinne Goldsmith Dickinson Center for MS (F.D.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (B.U.), MS Center Amsterdam, Amsterdam University Medical Centers, the Netherlands; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| | - Jerry S Wolinsky
- From the Departments of Clinical Neurosciences (M.W.K.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; Department of Neurology (J.P.M.), Rijnstate Hospital, Arnhem, the Netherlands; Department of Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth); Corinne Goldsmith Dickinson Center for MS (F.D.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (B.U.), MS Center Amsterdam, Amsterdam University Medical Centers, the Netherlands; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| | - Fred D Lublin
- From the Departments of Clinical Neurosciences (M.W.K.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; Department of Neurology (J.P.M.), Rijnstate Hospital, Arnhem, the Netherlands; Department of Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth); Corinne Goldsmith Dickinson Center for MS (F.D.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (B.U.), MS Center Amsterdam, Amsterdam University Medical Centers, the Netherlands; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| | - Bernard Uitdehaag
- From the Departments of Clinical Neurosciences (M.W.K.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; Department of Neurology (J.P.M.), Rijnstate Hospital, Arnhem, the Netherlands; Department of Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth); Corinne Goldsmith Dickinson Center for MS (F.D.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (B.U.), MS Center Amsterdam, Amsterdam University Medical Centers, the Netherlands; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| | - Gary R Cutter
- From the Departments of Clinical Neurosciences (M.W.K.) and Community Health Sciences (M.W.K.), University of Calgary, Alberta, Canada; Department of Neurology (J.P.M.), Rijnstate Hospital, Arnhem, the Netherlands; Department of Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth); Corinne Goldsmith Dickinson Center for MS (F.D.L.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (B.U.), MS Center Amsterdam, Amsterdam University Medical Centers, the Netherlands; and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham
| |
Collapse
|
13
|
Koch MW, Mostert J, Zhang Y, Wolinsky JS, Lublin FD, Strijbis E, Cutter G. Association of Age With Contrast-Enhancing Lesions Across the Multiple Sclerosis Disease Spectrum. Neurology 2021; 97:e1334-e1342. [PMID: 34376508 PMCID: PMC8589289 DOI: 10.1212/wnl.0000000000012603] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/20/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the association of age and the presence of contrast enhancing lesions (CELs) on cranial MRI scans in different disease courses of multiple sclerosis (MS), we describe the frequency of CELs as a function of age in four large randomized controlled trial (RCT) datasets. METHODS Using original trial data from CombiRx (clinicaltrials.gov identifier NCT00211887), a trial in relapsing-remitting MS, ASCEND (NCT01416181) a trial in secondary progressive MS, and the two primary progressive MS trials PROMISE and INFORMS (NCT00731692), we describe the occurrence of CELs per age group at baseline for the entire trial cohort, and at one year follow-up in the treatment arms. RESULTS CombiRx included 1,008, ASCEND 889, PROMISE 943, and INFORMS 970 participants. At baseline, CEL frequency differed between datasets according to disease courses: 39.6% of CombiRx, 23.9% of ASCEND, 14.0% of PROMISE, and 12.3% of INFORMS participants had CELs. This distribution by disease course was largely preserved within each age group. In all datasets, there was an almost linear decrease of the percentage of participants with CELs with advancing age. After one year of experimental treatment, CEL occurrence was reduced in all trial datasets, and almost absent in ASCEND. The decrease of CEL occurrence with advancing age was preserved in CombiRx, PROMISE and INFORMS after one year of treatment. We investigated the association of the baseline factors age, disease duration, sex and EDSS with having CELs at baseline with multivariable binary logistic regression models. Age was the only characteristic associated with the risk of CELs at baseline in all datasets, with higher age associated with a lower risk of CELs (odds ratios (OR) for having CELs at baseline per year increase in age: CombiRx: 0.96, 95% confidence interval (CI) 0.95 to 0.98, ASCEND: 0.94, 95% CI 0.92 to 0.97, PROMISE: OR 0.94, 95% CI 0.91 to 0.96, INFORMS: 0.97 95% CI 0.94 to 0.99). CONCLUSIONS Our analysis of four large, well-characterized RCT datasets shows that the association of age and CEL occurrence is a general phenomenon across the spectrum of MS disease courses. Our findings should be replicated in real world MS datasets.
Collapse
Affiliation(s)
- Marcus W Koch
- Department of Clinical Neurosciences, University of Calgary, Canada.,Department of Community Health Sciences, University of Calgary, Canada
| | - Jop Mostert
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Yinan Zhang
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Jerry S Wolinsky
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), USA
| | - Fred D Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Eva Strijbis
- Department of Neurology, MS Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, USA
| |
Collapse
|
14
|
Sumowski JF, Horng S, Brandstadter R, Krieger S, Leavitt VM, Katz Sand I, Fabian M, Klineova S, Graney R, Riley CS, Lublin FD, Miller AE, Varga AW. Sleep disturbance and memory dysfunction in early multiple sclerosis. Ann Clin Transl Neurol 2021; 8:1172-1182. [PMID: 33951348 PMCID: PMC8164863 DOI: 10.1002/acn3.51262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/21/2020] [Accepted: 11/02/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Sleep-dependent memory processing occurs in animals including humans, and disturbed sleep negatively affects memory. Sleep disturbance and memory dysfunction are common in multiple sclerosis (MS), but little is known about the contributions of sleep disturbance to memory in MS. We investigated whether subjective sleep disturbance is linked to worse memory in early MS independently of potential confounders. METHODS Persons with early MS (n = 185; ≤5.0 years diagnosed) and demographically matched healthy controls (n = 50) completed four memory tests to derive a memory composite, and four speeded tests to derive a cognitive efficiency composite. Z-scores were calculated relative to healthy controls. Sleep disturbance was defined by the Insomnia Severity Index score ≥ 10. ANCOVAs examined differences in memory and cognitive efficiency between patients with and without sleep disturbance controlling for potential confounds (e.g., mood, fatigue, disability, T2 lesion volume, gray matter volume). Comparisons were made to healthy controls. RESULTS Seventy-four (40%) patients reported sleep disturbance. Controlling for all covariates, patients with sleep disturbance had worse memory (z = -0.617; 95% CI: -0.886, -0.348) than patients without disturbance (z = -0.171, -0.425, 0.082, P = .003). Cognitive efficiency did not differ between groups. Relative to healthy controls, memory was worse among patients with sleep disturbance, but not among patients without sleep disturbance. INTERPRETATION Sleep disturbance contributes to MS memory dysfunction, which may help explain differential risk for memory dysfunction in persons with MS, especially since sleep disturbance is common in MS. Potential mechanisms linking sleep disturbance and memory are discussed, as well as recommendations for further mechanistic and interventional research.
Collapse
Affiliation(s)
- James F. Sumowski
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Sam Horng
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Rachel Brandstadter
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Stephen Krieger
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Victoria M. Leavitt
- Department of NeurologyColumbia University Medical CenterNew YorkNew YorkUSA
| | - Ilana Katz Sand
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Michelle Fabian
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Sylvia Klineova
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Robin Graney
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Claire S. Riley
- Department of NeurologyColumbia University Medical CenterNew YorkNew YorkUSA
| | - Fred D. Lublin
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Aaron E. Miller
- Department of NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Andrew W. Varga
- Icahn School of Medicine at Mount SinaiDivision of PulmonaryCritical Care and Sleep MedicineNew YorkNew YorkUSA
| |
Collapse
|
15
|
Marignier R, Bennett JL, Kim HJ, Weinshenker BG, Pittock SJ, Wingerchuk D, Fujihara K, Paul F, Cutter GR, Green AJ, Aktas O, Hartung HP, Lublin FD, Williams IM, Drappa J, She D, Cimbora D, Rees W, Smith M, Ratchford JN, Katz E, Cree BAC. Disability Outcomes in the N-MOmentum Trial of Inebilizumab in Neuromyelitis Optica Spectrum Disorder. Neurol Neuroimmunol Neuroinflamm 2021; 8:8/3/e978. [PMID: 33771837 PMCID: PMC8054974 DOI: 10.1212/nxi.0000000000000978] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/08/2021] [Indexed: 11/18/2022]
Abstract
Objective To assess treatment effects on Expanded Disability Status Scale (EDSS) score worsening and modified Rankin Scale (mRS) scores in the N-MOmentum trial of inebilizumab, a humanized anti-CD19 monoclonal antibody, in participants with neuromyelitis optica spectrum disorder (NMOSD). Methods Adults (N = 230) with aquaporin-4 immunoglobulin G-seropositive NMOSD or -seronegative neuromyelitis optica and an EDSS score ≤8 were randomized (3:1) to receive inebilizumab 300 mg or placebo on days 1 and 15. The randomized controlled period (RCP) was 28 weeks or until adjudicated attack, with an option to enter the inebilizumab open-label period. Three-month EDSS-confirmed disability progression (CDP) was assessed using a Cox proportional hazard model. The effect of baseline subgroups on disability was assessed by interaction tests. mRS scores from the RCP were analyzed by the Wilcoxon-Mann-Whitney odds approach. Results Compared with placebo, inebilizumab reduced the risk of 3-month CDP (hazard ratio [HR]: 0.375; 95% CI: 0.148–0.952; p = 0.0390). Baseline disability, prestudy attack frequency, and disease duration did not affect the treatment effect observed with inebilizumab (HRs: 0.213–0.503; interaction tests: all p > 0.05, indicating no effect of baseline covariates on outcome). Mean EDSS scores improved with longer-term treatment. Inebilizumab-treated participants were more likely to have a favorable mRS outcome at the end of the RCP (OR: 1.663; 95% CI: 1.195–2.385; p = 0.0023). Conclusions Disability outcomes were more favorable with inebilizumab vs placebo in participants with NMOSD. Classification of Evidence This study provides Class II evidence that for patients with NMOSD, inebilizumab reduces the risk of worsening disability. N-MOmentum is registered at ClinicalTrials.gov: NCT02200770.
Collapse
Affiliation(s)
- Romain Marignier
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco.
| | - Jeffrey L Bennett
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Ho Jin Kim
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Brian G Weinshenker
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Sean J Pittock
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Dean Wingerchuk
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Kazuko Fujihara
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Friedemann Paul
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Gary R Cutter
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Ari J Green
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Orhan Aktas
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Hans-Peter Hartung
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Fred D Lublin
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Ian M Williams
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Jorn Drappa
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Dewei She
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Daniel Cimbora
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - William Rees
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Michael Smith
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - John N Ratchford
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Eliezer Katz
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | - Bruce A C Cree
- From the Service de Neurologie Sclérose en Plaques (R.M.), Pathologies de La Myéline et Neuro-inflammation, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, France; University of Colorado School of Medicine (J.L.B.), Anschutz Medical Campus, Aurora; Research Institute and Hospital of National Cancer Center (H.J.K.), Goyang, South Korea; Mayo Clinic (B.G.W., S.J.P.), Rochester, MN; Mayo Clinic (D.W.), Scottsdale, AZ; Department of Multiple Sclerosis Therapeutics (K.F.), Fukushima Medical University and Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan; Experimental and Clinical Research Center (F.P.), Max Delbrück Center for Molecular Medicine and Charité-Universitätsmedizin Berlin, Germany; University of Alabama at Birmingham (G.R.C.); UCSF Weill Institute for Neurosciences (A.J.G.), Department of Neurology and Department of Ophthalmology, University of California San Francisco; Medical Faculty (O.A., H.-P.H.), Heinrich Heine University, Düsseldorf, Germany; Icahn School of Medicine at Mount Sinai (F.D.L.), New York; Oxford PharmaGenesis Ltd (I.M.W.), UK; Viela Bio (J.D., D.S., D.C., W.R., M.S., J.N.R., E.K.), Gaithersburg, MD; and UCSF Weill Institute for Neurosciences (B.A.C.C.), University of California San Francisco
| | | |
Collapse
|
16
|
Glukhovsky L, Kurz D, Brandstadter R, Leavitt VM, Krieger S, Fabian M, Katz Sand I, Klineova S, Riley CS, Lublin FD, Miller AE, Sumowski JF. Depression and cognitive function in early multiple sclerosis: Multitasking is more sensitive than traditional assessments. Mult Scler 2020; 27:1276-1283. [PMID: 33196404 PMCID: PMC10375894 DOI: 10.1177/1352458520958359] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Persons with multiple sclerosis (MS) and depression symptoms report real-world cognitive difficulties that may be missed by laboratory cognitive tests. OBJECTIVE To examine the relationship of depressive symptoms to cognitive monotasking versus multitasking in early MS. METHOD Persons with early MS (n = 185; ⩽5 years diagnosed) reported mood, completed monotasking and multitasking cognitive tests, and received high-resolution 3.0 T magnetic resonance imaging (MRI). Partial correlations analyzed associations between mood and cognition, controlling for age, sex, estimated premorbid IQ, T2 lesion volume, and normalized gray matter volume. RESULTS Depression symptoms were more related to worse cognitive multitasking (-0.353, p < 0.001) than monotasking (r = -0.189, p = 0.011). There was a significant albeit weaker link to cognitive efficiency composite score (r = -0.281, p < 0.001), but not composite memory (r = -0.036, p > 0.50). Findings were replicated with a second depression measure. Multitasking was worse in patients with at least mild depression than both patients with no/minimal depression and healthy controls. Multitasking was not related to mood in healthy controls. CONCLUSIONS Depression symptoms are linked to cognitive multitasking in early MS; standard monotasking cognitive assessments appear less sensitive to depression-related cognition. Further investigation should determine directionality and mechanisms of this relationship, with the goal of enhancing treatment for cognitive dysfunction and depression in MS.
Collapse
Affiliation(s)
- Lisa Glukhovsky
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Kurz
- Department of Neurology. Maimonides Medical Center, New York, NY, USA
| | | | - Victoria M Leavitt
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Stephen Krieger
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michelle Fabian
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ilana Katz Sand
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sylvia Klineova
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Claire S Riley
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Fred D Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aaron E Miller
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James F Sumowski
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
17
|
Cree BAC, Cutter G, Wolinsky JS, Freedman MS, Comi G, Giovannoni G, Hartung HP, Arnold D, Kuhle J, Block V, Munschauer FE, Sedel F, Lublin FD. Safety and efficacy of MD1003 (high-dose biotin) in patients with progressive multiple sclerosis (SPI2): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Neurol 2020; 19:988-997. [PMID: 33222767 DOI: 10.1016/s1474-4422(20)30347-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/28/2020] [Accepted: 09/03/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND There is an unmet need to develop therapeutic interventions directed at the neurodegeneration that underlies progression in multiple sclerosis. High-dose, pharmaceutical-grade biotin (MD1003) might enhance neuronal and oligodendrocyte energetics, resulting in improved cell function, repair, or survival. The MS-SPI randomised, double-blind, placebo-controlled study found that MD1003 improved disability outcomes over 12 months in patients with progressive multiple sclerosis. The SPI2 study was designed to assess the safety and efficacy of MD1003 in progressive forms of multiple sclerosis in a larger, more representative patient cohort. METHODS SPI2 was a randomised, double-blind, parallel-group, placebo-controlled trial done at 90 academic and community multiple sclerosis clinics across 13 countries. Patients were aged 18-65 years, had a diagnosis of primary or secondary progressive multiple sclerosis fulfilling the revised International Panel criteria and Lublin criteria, a Kurtzke pyramidal functional subscore of at least 2 (defined as minimal disability), an expanded disability status scale (EDSS) score of 3·5-6·5, a timed 25-foot walk (TW25) of less than 40 s, evidence of clinical disability progression, and no relapses in the 2 years before enrolment. Concomitant disease-modifying therapies were allowed. Patients were randomly assigned (1:1) by an independent statistician using an interactive web response system, with stratification by study site and disease history, to receive MD1003 (oral biotin 100 mg three times daily) or placebo. Participants, investigators, and assessors were masked to treatment assignment. The primary endpoint was a composite of the proportion of participants with confirmed improvement in EDSS or TW25 at month 12, confirmed at month 15, versus baseline. The primary endpoint was assessed in the intention-to-treat analysis set, after all participants completed the month 15 visit. Safety analyses included all participants who received at least one dose of MD1003. This trial is registered with ClinicalTrials.gov (NCT02936037) and the EudraCT database (2016-000700-29). FINDINGS From Feb 22, 2017, to June 8, 2018, 642 participants were randomly assigned MD1003 (n=326) or placebo (n=316). The double-blind, placebo-controlled phase of the study ended when the primary endpoint for the last-entered participant was assessed on Nov 15, 2019. The mean time in the placebo-controlled phase was 20·1 months (SD 5·3; range 15-27). For the primary outcome, 39 (12%) of 326 patients in the MD1003 group compared with 29 (9%) of 316 in the placebo group improved at month 12, with confirmation at month 15 (odds ratio 1·35 [95% CI 0·81-2·26]). Treatment-emergent adverse events occurred in 277 (84%) of 331 participants in the MD1003 group and in 264 (85%) of 311 in the placebo group. 87 (26%) of 331 participants in the MD1003 group and 82 (26%) of 311 participants in the placebo group had at least one serious treatment-emergent adverse event. One (<1%) person died in the MD1003 group and there were no deaths in the placebo group. Despite use of mitigation strategies, MD1003 led to inaccurate laboratory results for tests using biotinylated antibodies. INTERPRETATION This study showed that MD1003 did not significantly improve disability or walking speed in patients with progressive multiple sclerosis and thus, in addition to the potential of MD1003 for deleterious health consequences from interference of laboratory tests, MD1003 cannot be recommended for treatment of progressive multiple sclerosis. FUNDING MedDay Pharmaceuticals.
Collapse
Affiliation(s)
- Bruce A C Cree
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
| | - Gary Cutter
- University of Alabama, School of Public Health, Birmingham, AL, USA
| | - Jerry S Wolinsky
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mark S Freedman
- The University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Giancarlo Comi
- Institute of Experimental Neurology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Douglas Arnold
- Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine, and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Valerie Block
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Fred D Lublin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | |
Collapse
|
18
|
Glukhovsky L, Brandstadter R, Leavitt VM, Krieger S, Buyukturkoglu K, Fabian M, Sand IK, Klineova S, Riley CS, Lublin FD, Miller AE, Sumowski JF. Hippocampal volume is more related to patient-reported memory than objective memory performance in early multiple sclerosis. Mult Scler 2020; 27:568-578. [PMID: 32567468 DOI: 10.1177/1352458520922830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND When persons with multiple sclerosis (MS) report memory decline but objective memory performance is normal, there is a bias toward believing objective test results. OBJECTIVE Investigate whether subjective memory decline or objective memory performance is more related to hippocampal and hippocampal subfield volumes in early MS. METHODS Persons with early MS (n = 185; ⩽5.0 years diagnosed) completed a subjective memory questionnaire; an objective memory composite was derived from four memory tests. Total hippocampal and subfield volumes were derived from high-resolution 3.0 T magnetic resonance images (MRIs). Partial correlations assessed links between hippocampal volumes and both subjective and objective memory, controlling for age, sex, mood, and pre-morbid intelligence quotient (IQ). RESULTS Lower total hippocampal and CA1 volumes were related to worse subjective memory but not objective memory (controlling for multiple comparisons). Correlations between subjective memory and both CA1 and subiculum were significantly stronger than were correlations between objective memory and these subfields. Patients in the worst tertile of subjective memory complaints (but not objective memory) had lower hippocampal volumes than 35 demographically similar healthy controls. CONCLUSION Patient-report is inherently a longitudinal assessment of within-person memory change in everyday life, which may be more sensitive to subtle disease-related changes than cross-sectional objective tests. Findings align with the aging literature.
Collapse
Affiliation(s)
- Lisa Glukhovsky
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Victoria M Leavitt
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Stephen Krieger
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Korhan Buyukturkoglu
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Michelle Fabian
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ilana Katz Sand
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sylvia Klineova
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Claire S Riley
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Fred D Lublin
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aaron E Miller
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James F Sumowski
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
19
|
Lublin FD, Coetzee T, Cohen JA, Marrie RA, Thompson AJ. The 2013 clinical course descriptors for multiple sclerosis: A clarification. Neurology 2020; 94:1088-1092. [PMID: 32471886 PMCID: PMC7455332 DOI: 10.1212/wnl.0000000000009636] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/01/2020] [Indexed: 11/28/2022] Open
Abstract
The clinical courses of multiple sclerosis were defined in 1996 and refined in 2013 to provide a time-based assessment of the current status of the individual. These definitions have been successfully used by clinicians, clinical trialists, and regulatory authorities. Recent regulatory decisions produced variations and discrepancies in the use of the clinical course descriptions. We provide here a clarification of the concepts underlying these descriptions and restate the principles used in their development. Importantly, we highlight the critical importance of time framing the disease course modifiers activity and progression and clarify the difference between the terms worsening and progressing.
Collapse
Affiliation(s)
- Fred D Lublin
- From the Department of Neurology (F.D.L.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; National Multiple Sclerosis Society (T.C.), New York, NY; Department of Neurology (J.A.C.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, OH; Departments of Internal Medicine (Neurology) and Community Health Sciences (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; and Faculty of Brain Sciences (A.J.T.), University College, London, United Kingdom.
| | - Timothy Coetzee
- From the Department of Neurology (F.D.L.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; National Multiple Sclerosis Society (T.C.), New York, NY; Department of Neurology (J.A.C.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, OH; Departments of Internal Medicine (Neurology) and Community Health Sciences (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; and Faculty of Brain Sciences (A.J.T.), University College, London, United Kingdom
| | - Jeffrey A Cohen
- From the Department of Neurology (F.D.L.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; National Multiple Sclerosis Society (T.C.), New York, NY; Department of Neurology (J.A.C.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, OH; Departments of Internal Medicine (Neurology) and Community Health Sciences (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; and Faculty of Brain Sciences (A.J.T.), University College, London, United Kingdom
| | - Ruth A Marrie
- From the Department of Neurology (F.D.L.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; National Multiple Sclerosis Society (T.C.), New York, NY; Department of Neurology (J.A.C.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, OH; Departments of Internal Medicine (Neurology) and Community Health Sciences (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; and Faculty of Brain Sciences (A.J.T.), University College, London, United Kingdom
| | - Alan J Thompson
- From the Department of Neurology (F.D.L.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; National Multiple Sclerosis Society (T.C.), New York, NY; Department of Neurology (J.A.C.), Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, OH; Departments of Internal Medicine (Neurology) and Community Health Sciences (R.A.M.), Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada; and Faculty of Brain Sciences (A.J.T.), University College, London, United Kingdom
| | | |
Collapse
|
20
|
Fitzgerald KC, Kim K, Smith MD, Aston SA, Fioravante N, Rothman AM, Krieger S, Cofield SS, Kimbrough DJ, Bhargava P, Saidha S, Whartenby KA, Green AJ, Mowry EM, Cutter GR, Lublin FD, Baranzini SE, De Jager PL, Calabresi PA. Early complement genes are associated with visual system degeneration in multiple sclerosis. Brain 2020; 142:2722-2736. [PMID: 31289819 DOI: 10.1093/brain/awz188] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 04/17/2019] [Accepted: 04/28/2019] [Indexed: 11/12/2022] Open
Abstract
Multiple sclerosis is a heterogeneous disease with an unpredictable course and a wide range of severity; some individuals rapidly progress to a disabled state whereas others experience only mild symptoms. Though genetic studies have identified variants that are associated with an increased risk of developing multiple sclerosis, no variants have been consistently associated with multiple sclerosis severity. In part, the lack of findings is related to inherent limitations of clinical rating scales; these scales are insensitive to early degenerative changes that underlie disease progression. Optical coherence tomography imaging of the retina and low-contrast letter acuity correlate with and predict clinical and imaging-based outcomes in multiple sclerosis. Therefore, they may serve as sensitive phenotypes to discover genetic predictors of disease course. We conducted a set of genome-wide association studies of longitudinal structural and functional visual pathway phenotypes in multiple sclerosis. First, we assessed genetic predictors of ganglion cell/inner plexiform layer atrophy in a discovery cohort of 374 patients with multiple sclerosis using mixed-effects models adjusting for age, sex, disease duration, optic neuritis and genetic ancestry and using a combination of single-variant and network-based analyses. For candidate variants identified in discovery, we conducted a similar set of analyses of ganglion cell/inner plexiform layer thinning in a replication cohort (n = 376). Second, we assessed genetic predictors of sustained loss of 5-letters in low-contrast letter acuity in discovery (n = 582) using multivariable-adjusted Cox proportional hazards models. We then evaluated candidate variants/pathways in a replication cohort. (n = 253). Results of both studies revealed novel subnetworks highly enriched for connected genes in early complement activation linked to measures of disease severity. Within these networks, C3 was the gene most strongly associated with ganglion cell/inner plexiform layer atrophy (P = 0.004) and C1QA and CR1 were top results in analysis of sustained low-contrast letter acuity loss. Namely, variant rs158772, linked to C1QA, and rs61822967, linked to CR1, were associated with 71% and 40% increases in risk of sustained LCLA loss, respectively, in meta-analysis pooling discovery and replication cohorts (rs158772: hazard ratio: 1.71; 95% confidence interval 1.30-2.25; P = 1.3 × 10-4; rs61822967: hazard ratio: 1.40; 95% confidence interval: 1.16-1.68; P = 4.1 × 10-4). In conclusion, early complement pathway gene variants were consistently associated with structural and functional measures of multiple sclerosis severity. These results from unbiased analyses are strongly supported by several prior reports that mechanistically implicated early complement factors in neurodegeneration.
Collapse
Affiliation(s)
| | - Kicheol Kim
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Matthew D Smith
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sean A Aston
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nicholas Fioravante
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Alissa M Rothman
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Stephen Krieger
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stacey S Cofield
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Pavan Bhargava
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Shiv Saidha
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Katharine A Whartenby
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ari J Green
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Fred D Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sergio E Baranzini
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Philip L De Jager
- Center for Translational and Computational Neuroimmunology, Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Cell Circuits Program, Broad Institute, Cambridge, MA, USA
| | - Peter A Calabresi
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Solomon Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
21
|
Narayana PA, Coronado I, Sujit SJ, Wolinsky JS, Lublin FD, Gabr RE. Deep-Learning-Based Neural Tissue Segmentation of MRI in Multiple Sclerosis: Effect of Training Set Size. J Magn Reson Imaging 2020; 51:1487-1496. [PMID: 31625650 PMCID: PMC7165037 DOI: 10.1002/jmri.26959] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The dependence of deep-learning (DL)-based segmentation accuracy of brain MRI on the training size is not known. PURPOSE To determine the required training size for a desired accuracy in brain MRI segmentation in multiple sclerosis (MS) using DL. STUDY TYPE Retrospective analysis of MRI data acquired as part of a multicenter clinical trial. STUDY POPULATION In all, 1008 patients with clinically definite MS. FIELD STRENGTH/SEQUENCE MRIs were acquired at 1.5T and 3T scanners manufactured by GE, Philips, and Siemens with dual turbo spin echo, FLAIR, and T1 -weighted turbo spin echo sequences. ASSESSMENT Segmentation results using an automated analysis pipeline and validated by two neuroimaging experts served as the ground truth. A DL model, based on a fully convolutional neural network, was trained separately using 16 different training sizes. The segmentation accuracy as a function of the training size was determined. These data were fitted to the learning curve for estimating the required training size for desired accuracy. STATISTICAL TESTS The performance of the network was evaluated by calculating the Dice similarity coefficient (DSC), and lesion true-positive and false-positive rates. RESULTS The DSC for lesions showed much stronger dependency on the sample size than gray matter (GM), white matter (WM), and cerebrospinal fluid (CSF). When the training size was increased from 10 to 800 the DSC values varied from 0.00 to 0.86 ± 0.016 for T2 lesions, 0.87 ± 009 to 0.94 ± 0.004 for GM, 0.86 ± 0.08 to 0.94 ± 0.005 for WM, and 0.91 ± 0.009 to 0.96 ± 0.003 for CSF. DATA CONCLUSION Excellent segmentation was achieved with a training size as small as 10 image volumes for GM, WM, and CSF. In contrast, a training size of at least 50 image volumes was necessary for adequate lesion segmentation. LEVEL OF EVIDENCE 1 Technical Efficacy Stage: 1 J. Magn. Reson. Imaging 2020;51:1487-1496.
Collapse
Affiliation(s)
- Ponnada A. Narayana
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Ivan Coronado
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Sheeba J. Sujit
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Jerry S. Wolinsky
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| | - Fred D. Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Refaat E. Gabr
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center, Houston, Texas, USA
| |
Collapse
|
22
|
Brandstadter R, Ayeni O, Krieger SC, Harel NY, Escalon MX, Katz Sand I, Leavitt VM, Fabian MT, Buyukturkoglu K, Klineova S, Riley CS, Lublin FD, Miller AE, Sumowski JF. Detection of subtle gait disturbance and future fall risk in early multiple sclerosis. Neurology 2020; 94:e1395-e1406. [PMID: 32102980 DOI: 10.1212/wnl.0000000000008938] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 10/05/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To test the hypothesis that higher-challenge gait and balance tasks are more sensitive than traditional metrics to subtle patient-reported gait dysfunction and future fall risk in early multiple sclerosis (MS). METHODS Persons with early MS (n = 185; ≤5 years diagnosed) reported gait function (MS Walking Scale) and underwent traditional disability metrics (Expanded Disability Status Scale [EDSS], Timed 25 Foot Walk). Patients and healthy controls (n = 50) completed clinically feasible challenge tasks of gait endurance (2-Minute Walk Test), standing balance (NIH Toolbox), and dynamic balance (balance boards; tandem walk on 2 ten-foot boards of different widths, 4.5 and 1.5 in). MRI assessed global and regional brain volumes, total T2 lesion volume (T2LV), infratentorial T2LVs and counts, and cervical cord lesion counts. Falls, near falls, and fall-related injuries were assessed after 1 year. We examined links between all tasks and patient-reported gait, MRI markers, and fall data. RESULTS Patients performed worse on higher challenge balance, but not gait, tasks compared with healthy controls. Worse patient-reported gait disturbance was associated with worse performance on all tasks, but only dynamic balance was sensitive to mild patient-reported gait difficulty. Balance tasks were more correlated with MRI metrics than were walking tasks or EDSS score. Thirty percent of patients reported either a fall or near fall after 1 year, with poor dynamic balance as the only task independently predicting falls. CONCLUSIONS Balance plays a leading role in gait dysfunction early in MS. Clinically feasible higher-challenge balance tasks were most sensitive to patient-reported gait, MRI disease markers, and risk of future falls, highlighting potential to advance functional outcomes in clinical practice and trials.
Collapse
Affiliation(s)
- Rachel Brandstadter
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Oluwasheyi Ayeni
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Stephen C Krieger
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Noam Y Harel
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Miguel X Escalon
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Ilana Katz Sand
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Victoria M Leavitt
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Michelle T Fabian
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Korhan Buyukturkoglu
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Sylvia Klineova
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Claire S Riley
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Fred D Lublin
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - Aaron E Miller
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY
| | - James F Sumowski
- From the Department of Neurology (R.B.), University of Pennsylvania, Philadelphia; Department of Neurology (O.A.), Kaiser Permanente, Atlanta, GA; Department of Neurology (S.C.K., N.Y.H., M.X.E., I.K.S., M.T.F., S.K., F.D.L., A.E.M., J.F.S.), Icahn School of Medicine at Mount Sinai; James J. Peters Veterans Affairs Medical Center (N.Y.H.); and Department of Neurology (V.M.L, K.B., C.S.R..), Columbia University Medical Center, New York, NY.
| |
Collapse
|
23
|
Narayana PA, Coronado I, Sujit SJ, Wolinsky JS, Lublin FD, Gabr RE. Deep Learning for Predicting Enhancing Lesions in Multiple Sclerosis from Noncontrast MRI. Radiology 2019; 294:398-404. [PMID: 31845845 DOI: 10.1148/radiol.2019191061] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Enhancing lesions on MRI scans obtained after contrast material administration are commonly thought to represent disease activity in multiple sclerosis (MS); it is desirable to develop methods that can predict enhancing lesions without the use of contrast material. Purpose To evaluate whether deep learning can predict enhancing lesions on MRI scans obtained without the use of contrast material. Materials and Methods This study involved prospective analysis of existing MRI data. A convolutional neural network was used for classification of enhancing lesions on unenhanced MRI scans. This classification was performed for each slice, and the slice scores were combined by using a fully connected network to produce participant-wise predictions. The network input consisted of 1970 multiparametric MRI scans from 1008 patients recruited from 2005 to 2009. Enhanced lesions on postcontrast T1-weighted images served as the ground truth. The network performance was assessed by using fivefold cross-validation. Statistical analysis of the network performance included calculation of lesion detection rates and areas under the receiver operating characteristic curve (AUCs). Results MRI scans from 1008 participants (mean age, 37.7 years ± 9.7; 730 women) were analyzed. At least one enhancing lesion was observed in 519 participants. The sensitivity and specificity averaged across the five test sets were 78% ± 4.3 and 73% ± 2.7, respectively, for slice-wise prediction. The corresponding participant-wise values were 72% ± 9.0 and 70% ± 6.3. The diagnostic performances (AUCs) were 0.82 ± 0.02 and 0.75 ± 0.03 for slice-wise and participant-wise enhancement prediction, respectively. Conclusion Deep learning used with conventional MRI identified enhanced lesions in multiple sclerosis from images from unenhanced multiparametric MRI with moderate to high accuracy. © RSNA, 2019.
Collapse
Affiliation(s)
- Ponnada A Narayana
- From the Departments of Diagnostic and Interventional Imaging (P.A.N., I.C., S.J.S., R.E.G.) and Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin St, Houston, TX 77030; and Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574 (F.D.L.)
| | - Ivan Coronado
- From the Departments of Diagnostic and Interventional Imaging (P.A.N., I.C., S.J.S., R.E.G.) and Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin St, Houston, TX 77030; and Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574 (F.D.L.)
| | - Sheeba J Sujit
- From the Departments of Diagnostic and Interventional Imaging (P.A.N., I.C., S.J.S., R.E.G.) and Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin St, Houston, TX 77030; and Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574 (F.D.L.)
| | - Jerry S Wolinsky
- From the Departments of Diagnostic and Interventional Imaging (P.A.N., I.C., S.J.S., R.E.G.) and Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin St, Houston, TX 77030; and Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574 (F.D.L.)
| | - Fred D Lublin
- From the Departments of Diagnostic and Interventional Imaging (P.A.N., I.C., S.J.S., R.E.G.) and Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin St, Houston, TX 77030; and Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574 (F.D.L.)
| | - Refaat E Gabr
- From the Departments of Diagnostic and Interventional Imaging (P.A.N., I.C., S.J.S., R.E.G.) and Neurology (J.S.W.), McGovern Medical School, University of Texas Health Science Center, 6431 Fannin St, Houston, TX 77030; and Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574 (F.D.L.)
| |
Collapse
|
24
|
Brandstadter R, Fabian M, Leavitt VM, Krieger S, Yeshokumar A, Katz Sand I, Klineova S, Riley CS, Lewis C, Pelle G, Lublin FD, Miller AE, Sumowski JF. Word-finding difficulty is a prevalent disease-related deficit in early multiple sclerosis. Mult Scler 2019; 26:1752-1764. [PMID: 31741430 DOI: 10.1177/1352458519881760] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Persons with multiple sclerosis (MS) commonly report word-finding difficulty clinically, yet this language deficit remains underexplored. OBJECTIVE To investigate the prevalence and nature of word-finding difficulty in persons with early MS on three levels: patient report, cognitive substrates, and neuroimaging. METHODS Two samples of early MS patients (n = 185 and n = 55; ⩽5 years diagnosed) and healthy controls (n = 50) reported frequency/severity of cognitive deficits and underwent objective assessment with tasks of rapid automatized naming (RAN), measuring lexical access speed, memory, word generation, and cognitive efficiency. High-resolution brain magnetic resonance imaging (MRI) derived measurements of regional cortical thickness, global and deep gray matter volume, and T2 lesion volume. Relationships among patient-reported word-finding difficulty, cognitive performance, and neural correlates were examined. RESULTS Word-finding difficulty was the most common cognitive complaint of MS patients and the only complaint reported more by patients than healthy controls. Only RAN performance discriminated MS patients with subjective word-finding deficits from those without subjective complaints and from healthy controls. Thinner left parietal cortical gray matter independently predicted impaired RAN performance, driven primarily by the left precuneus. CONCLUSION Three levels of evidence (patient-report, objective behavior, regional gray matter) support word-finding difficulty as a prevalent, measurable, disease-related deficit in early MS linked to left parietal cortical thinning.
Collapse
Affiliation(s)
- Rachel Brandstadter
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michelle Fabian
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Victoria M Leavitt
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Stephen Krieger
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anusha Yeshokumar
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ilana Katz Sand
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sylvia Klineova
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Claire S Riley
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Christina Lewis
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabrielle Pelle
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Fred D Lublin
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aaron E Miller
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James F Sumowski
- The Corinne Goldsmith Dickinson Center for MS, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
25
|
Cree BAC, Bennett JL, Kim HJ, Weinshenker BG, Pittock SJ, Wingerchuk DM, Fujihara K, Paul F, Cutter GR, Marignier R, Green AJ, Aktas O, Hartung HP, Lublin FD, Drappa J, Barron G, Madani S, Ratchford JN, She D, Cimbora D, Katz E. Inebilizumab for the treatment of neuromyelitis optica spectrum disorder (N-MOmentum): a double-blind, randomised placebo-controlled phase 2/3 trial. Lancet 2019; 394:1352-1363. [PMID: 31495497 DOI: 10.1016/s0140-6736(19)31817-3] [Citation(s) in RCA: 363] [Impact Index Per Article: 72.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND No approved therapies exist for neuromyelitis optica spectrum disorder (NMOSD), a rare, relapsing, autoimmune, inflammatory disease of the CNS that causes blindness and paralysis. We aimed to assess the efficacy and safety of inebilizumab, an anti-CD19, B cell-depleting antibody, in reducing the risk of attacks and disability in NMOSD. METHODS We did a multicentre, double-blind, randomised placebo-controlled phase 2/3 study at 99 outpatient specialty clinics or hospitals in 25 countries. Eligible participants were adults (≥18 years old) with a diagnosis of NMOSD, an Expanded Disability Status Scale score of 8·0 or less, and a history of at least one attack requiring rescue therapy in the year before screening or at least two attacks requiring rescue therapy in the 2 years before screening. Participants were randomly allocated (3:1) to 300 mg intravenous inebilizumab or placebo with a central interactive voice response system or interactive web response system and permuted block randomisation. Inebilizumab or placebo was administered on days 1 and 15. Participants, investigators, and all clinical staff were masked to the treatments, and inebilizumab and placebo were indistinguishable in appearance. The primary endpoint was time to onset of an NMOSD attack, as determined by the adjudication committee. Efficacy endpoints were assessed in all randomly allocated patients who received at least one dose of study intervention, and safety endpoints were assessed in the as-treated population. The study is registered with ClinicalTrials.gov, number NCT02200770. FINDINGS Between Jan 6, 2015, and Sept 24, 2018, 230 participants were randomly assigned to treatment and dosed, with 174 participants receiving inebilizumab and 56 receiving placebo. The randomised controlled period was stopped before complete enrolment, as recommended by the independent data-monitoring committee, because of a clear demonstration of efficacy. 21 (12%) of 174 participants receiving inebilizumab had an attack versus 22 (39%) of 56 participants receiving placebo (hazard ratio 0·272 [95% CI 0·150-0·496]; p<0·0001). Adverse events occurred in 125 (72%) of 174 participants receiving inebilizumab and 41 (73%) of 56 participants receiving placebo. Serious adverse events occurred in eight (5%) of 174 participants receiving inebilizumab and five (9%) of 56 participants receiving placebo. INTERPRETATION Compared with placebo, inebilizumab reduced the risk of an NMOSD attack. Inebilizumab has potential application as an evidence-based treatment for patients with NMOSD. FUNDING MedImmune and Viela Bio.
Collapse
Affiliation(s)
- Bruce A C Cree
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
| | - Jeffrey L Bennett
- School of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Ho Jin Kim
- Research Institute and Hospital of National Cancer Center, Seoul, South Korea
| | | | | | | | - Kazuo Fujihara
- Department of Multiple Sclerosis Therapeutics, Fukushima Medical University, Fukushima, Japan; Multiple Sclerosis and Neuromyelitis Optica Center, Southern Tohoku Research Institute for Neuroscience, Koriyama, Japan
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine, Berlin, Germany; Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Romain Marignier
- Service de Neurologie, Sclérose en Plaques, Pathologies de la Myéline et Neuro-inflammation, Lyon University Hospital, Lyon, France
| | - Ari J Green
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA, USA; Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Orhan Aktas
- Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | | | - Fred D Lublin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Fox EJ, Lublin FD, Wolinsky JS, Cohen JA, Williams IM, Meng X, Ziehn M, Kolodny S, Cree BAC. Lymphocyte counts and infection rates: Long-term fingolimod treatment in primary progressive MS. Neurol Neuroimmunol Neuroinflamm 2019; 6:6/6/e614. [PMID: 31511330 PMCID: PMC6745722 DOI: 10.1212/nxi.0000000000000614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 07/01/2019] [Indexed: 12/02/2022]
Abstract
Objective To evaluate lymphocyte counts and incidences of infections in patients with primary progressive MS (PPMS) receiving fingolimod 0.5 mg/d or placebo over 5 years during the INFORMS study, to assess infection rates with longer-term treatment. Methods INFORMS was a randomized, multicenter, double-blind, placebo-controlled, parallel-group, phase 3 study of the sphingosine 1-phosphate receptor modulator fingolimod in patients with PPMS. Lymphocyte counts and incidences of infections were compared in patients receiving fingolimod or placebo. Infection rates were assessed in patients receiving fingolimod according to nadir and mean absolute lymphocyte count (ALC). Results Overall, 336 patients received fingolimod 0.5 mg/d (total exposure: 908.1 patient-years), and 487 received placebo (1,423.5 patient-years). In patients receiving fingolimod, mean ALC decreased by approximately 70% in the 2 weeks following treatment initiation and remained stable throughout the study. The incidences of all infections in the fingolimod and placebo groups were similar (53.6 vs 51.9 per 100 patient-years). The most common infections in patients receiving fingolimod were urinary tract infections (5.7 per 100 patient-years), upper respiratory tract infections (4.2 per 100 patient-years), and influenza (3.2 per 100 patient-years); incidences were similar in the placebo group (5.9, 4.2, and 3.1 per 100 patient-years, respectively). There was no apparent association between nadir or mean ALC and incidence of infection-related adverse events. Conclusions In patients with PPMS, long-term treatment with fingolimod 0.5 mg/d for up to 5 years led to an expected decrease of approximately 70% in mean ALC and did not appear to correlate with increased risk of infection. Classification of evidence Because this is a secondary analysis, this study provides Class II evidence that long-term PPMS treatment with fingolimod decreased mean ALC by approximately 70%, but did not significantly increase infection risk.
Collapse
Affiliation(s)
- Edward J Fox
- From the Central Texas Neurology Consultants (E.J.F.), Round Rock, TX; Icahn School of Medicine at Mount Sinai (F.D.L.), New York, NY; McGovern Medical School (J.S.W.), The University of Texas Health Science Center at Houston (UTHealth), TX; Mellen Center for Multiple Sclerosis Treatment and Research (J.A.C.), Neurological Institute, Cleveland Clinic Foundation, OH; Oxford PharmaGenesis Ltd (I.M.W.), UK; Novartis Pharmaceuticals Corporation (X.M., M.Z., S.K.), East Hanover, NJ; and The University of California, San Francisco (UCSF); Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), San Francisco, CA.
| | - Fred D Lublin
- From the Central Texas Neurology Consultants (E.J.F.), Round Rock, TX; Icahn School of Medicine at Mount Sinai (F.D.L.), New York, NY; McGovern Medical School (J.S.W.), The University of Texas Health Science Center at Houston (UTHealth), TX; Mellen Center for Multiple Sclerosis Treatment and Research (J.A.C.), Neurological Institute, Cleveland Clinic Foundation, OH; Oxford PharmaGenesis Ltd (I.M.W.), UK; Novartis Pharmaceuticals Corporation (X.M., M.Z., S.K.), East Hanover, NJ; and The University of California, San Francisco (UCSF); Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), San Francisco, CA
| | - Jerry S Wolinsky
- From the Central Texas Neurology Consultants (E.J.F.), Round Rock, TX; Icahn School of Medicine at Mount Sinai (F.D.L.), New York, NY; McGovern Medical School (J.S.W.), The University of Texas Health Science Center at Houston (UTHealth), TX; Mellen Center for Multiple Sclerosis Treatment and Research (J.A.C.), Neurological Institute, Cleveland Clinic Foundation, OH; Oxford PharmaGenesis Ltd (I.M.W.), UK; Novartis Pharmaceuticals Corporation (X.M., M.Z., S.K.), East Hanover, NJ; and The University of California, San Francisco (UCSF); Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), San Francisco, CA
| | - Jeffrey A Cohen
- From the Central Texas Neurology Consultants (E.J.F.), Round Rock, TX; Icahn School of Medicine at Mount Sinai (F.D.L.), New York, NY; McGovern Medical School (J.S.W.), The University of Texas Health Science Center at Houston (UTHealth), TX; Mellen Center for Multiple Sclerosis Treatment and Research (J.A.C.), Neurological Institute, Cleveland Clinic Foundation, OH; Oxford PharmaGenesis Ltd (I.M.W.), UK; Novartis Pharmaceuticals Corporation (X.M., M.Z., S.K.), East Hanover, NJ; and The University of California, San Francisco (UCSF); Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), San Francisco, CA
| | - Ian M Williams
- From the Central Texas Neurology Consultants (E.J.F.), Round Rock, TX; Icahn School of Medicine at Mount Sinai (F.D.L.), New York, NY; McGovern Medical School (J.S.W.), The University of Texas Health Science Center at Houston (UTHealth), TX; Mellen Center for Multiple Sclerosis Treatment and Research (J.A.C.), Neurological Institute, Cleveland Clinic Foundation, OH; Oxford PharmaGenesis Ltd (I.M.W.), UK; Novartis Pharmaceuticals Corporation (X.M., M.Z., S.K.), East Hanover, NJ; and The University of California, San Francisco (UCSF); Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), San Francisco, CA
| | - Xiangyi Meng
- From the Central Texas Neurology Consultants (E.J.F.), Round Rock, TX; Icahn School of Medicine at Mount Sinai (F.D.L.), New York, NY; McGovern Medical School (J.S.W.), The University of Texas Health Science Center at Houston (UTHealth), TX; Mellen Center for Multiple Sclerosis Treatment and Research (J.A.C.), Neurological Institute, Cleveland Clinic Foundation, OH; Oxford PharmaGenesis Ltd (I.M.W.), UK; Novartis Pharmaceuticals Corporation (X.M., M.Z., S.K.), East Hanover, NJ; and The University of California, San Francisco (UCSF); Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), San Francisco, CA
| | - Marina Ziehn
- From the Central Texas Neurology Consultants (E.J.F.), Round Rock, TX; Icahn School of Medicine at Mount Sinai (F.D.L.), New York, NY; McGovern Medical School (J.S.W.), The University of Texas Health Science Center at Houston (UTHealth), TX; Mellen Center for Multiple Sclerosis Treatment and Research (J.A.C.), Neurological Institute, Cleveland Clinic Foundation, OH; Oxford PharmaGenesis Ltd (I.M.W.), UK; Novartis Pharmaceuticals Corporation (X.M., M.Z., S.K.), East Hanover, NJ; and The University of California, San Francisco (UCSF); Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), San Francisco, CA
| | - Scott Kolodny
- From the Central Texas Neurology Consultants (E.J.F.), Round Rock, TX; Icahn School of Medicine at Mount Sinai (F.D.L.), New York, NY; McGovern Medical School (J.S.W.), The University of Texas Health Science Center at Houston (UTHealth), TX; Mellen Center for Multiple Sclerosis Treatment and Research (J.A.C.), Neurological Institute, Cleveland Clinic Foundation, OH; Oxford PharmaGenesis Ltd (I.M.W.), UK; Novartis Pharmaceuticals Corporation (X.M., M.Z., S.K.), East Hanover, NJ; and The University of California, San Francisco (UCSF); Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), San Francisco, CA
| | - Bruce A C Cree
- From the Central Texas Neurology Consultants (E.J.F.), Round Rock, TX; Icahn School of Medicine at Mount Sinai (F.D.L.), New York, NY; McGovern Medical School (J.S.W.), The University of Texas Health Science Center at Houston (UTHealth), TX; Mellen Center for Multiple Sclerosis Treatment and Research (J.A.C.), Neurological Institute, Cleveland Clinic Foundation, OH; Oxford PharmaGenesis Ltd (I.M.W.), UK; Novartis Pharmaceuticals Corporation (X.M., M.Z., S.K.), East Hanover, NJ; and The University of California, San Francisco (UCSF); Weill Institute for Neurosciences, Department of Neurology (B.A.C.C.), San Francisco, CA
| |
Collapse
|
27
|
Gabr RE, Coronado I, Robinson M, Sujit SJ, Datta S, Sun X, Allen WJ, Lublin FD, Wolinsky JS, Narayana PA. Brain and lesion segmentation in multiple sclerosis using fully convolutional neural networks: A large-scale study. Mult Scler 2019; 26:1217-1226. [PMID: 31190607 DOI: 10.1177/1352458519856843] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate the performance of deep learning (DL) based on fully convolutional neural network (FCNN) in segmenting brain tissues in a large cohort of multiple sclerosis (MS) patients. METHODS We developed a FCNN model to segment brain tissues, including T2-hyperintense MS lesions. The training, validation, and testing of FCNN were based on ~1000 magnetic resonance imaging (MRI) datasets acquired on relapsing-remitting MS patients, as a part of a phase 3 randomized clinical trial. Multimodal MRI data (dual-echo, FLAIR, and T1-weighted images) served as input to the network. Expert validated segmentation was used as the target for training the FCNN. We cross-validated our results using the leave-one-center-out approach. RESULTS We observed a high average (95% confidence limits) Dice similarity coefficient for all the segmented tissues: 0.95 (0.92-0.98) for white matter, 0.96 (0.93-0.98) for gray matter, 0.99 (0.98-0.99) for cerebrospinal fluid, and 0.82 (0.63-1.0) for T2 lesions. High correlations between the DL segmented tissue volumes and ground truth were observed (R2 > 0.92 for all tissues). The cross validation showed consistent results across the centers for all tissues. CONCLUSION The results from this large-scale study suggest that deep FCNN can automatically segment MS brain tissues, including lesions, with high accuracy.
Collapse
Affiliation(s)
- Refaat E Gabr
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Ivan Coronado
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Melvin Robinson
- Department of Electrical Engineering, The University of Texas at Tyler, Houston, TX, USA
| | - Sheeba J Sujit
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Sushmita Datta
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Xiaojun Sun
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - William J Allen
- Texas Advanced Computing Center, The University of Texas at Austin, Austin, TX, USA
| | | | - Jerry S Wolinsky
- Department of Neurology, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Ponnada A Narayana
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| |
Collapse
|
28
|
Margoni M, Petracca M, Schiavi S, Fabian M, Miller A, Lublin FD, Inglese M. Axonal water fraction as marker of white matter injury in primary-progressive multiple sclerosis: a longitudinal study. Eur J Neurol 2019; 26:1068-1074. [PMID: 30761708 DOI: 10.1111/ene.13937] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 02/05/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND PURPOSE Diffuse white matter (WM) injury is prominent in primary-progressive multiple sclerosis (PP-MS) pathology and is a potential biomarker of disease progression. Diffusion kurtosis imaging allows the quantification of non-Gaussian water diffusion, providing metrics with high WM pathological specificity. The aim of this study was to characterize the pathological changes occurring in the normal-appearing WM of patients with PP-MS at baseline and at 1-year follow-up and to assess their impact on disability and short-term disease progression. METHODS A total of 26 patients with PP-MS and 20 healthy controls were prospectively enrolled. Diffusion kurtosis imaging single-shot echo-planar imaging (EPI) was acquired on a 3-T scanner (Philips Achieva, Best, The Netherlands) (voxel size, 2 × 2 × 2 mm3 , 30 directions for each b-value = 1000, 2000 s/mm2 and one b = 0 s/mm2 ). A two-compartment biophysical model of WM tract integrity was used to derive spatial maps of axonal water fraction (AWF), intra-axonal diffusivity, extra-axonal axial and radial diffusivities (De,axial , De,radial ) and tortuosity from the following WM tracts: corpus callosum (CC), corticospinal tract (CST) and posterior thalamic radiation (PTR). RESULTS At baseline, patients with PP-MS showed a widespread decrease of AWF, tortuosity and De,axial and an increase of De,radial in CC, CST and PTR (P ranging from 0.001 to 0.036). At 1-year follow-up, a significant AWF decrease was detected in the body of CC (P = 0.048), PTR (P = 0.008) and CST (P = 0.044). Baseline AWF values in CST significantly discriminated progressed from non-progressed patients (P = 0.021; area under the curve, 0.854). CONCLUSION Based on its change over time and its relationship with disease progression, among the analyzed metrics, AWF seems the most sensitive metric of WM tissue damage in PP-MS and therefore it could be considered as a marker for monitoring disease progression.
Collapse
Affiliation(s)
- M Margoni
- Multiple Sclerosis Centre, Department of Neuroscience DNS, University Hospital, University of Padua, Padua, Italy.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M Petracca
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - S Schiavi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Perinatal Sciences, University of Genoa, Genoa.,IRCSS Azienda Ospedale Università San Martino-IST, Genoa, Italy
| | - M Fabian
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Miller
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - F D Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M Inglese
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Perinatal Sciences, University of Genoa, Genoa.,IRCSS Azienda Ospedale Università San Martino-IST, Genoa, Italy.,Department of Radiology and Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
29
|
Abstract
The 1996 originally established multiple sclerosis (MS) subtypes, based solely on clinical impression and consensus, were revised in 2013 to review potential imaging and biological correlates and to reflect recently identified clinical aspects of MS. As a result, potential new disease phenotypes, radiologically isolated syndrome, and clinically isolated syndrome were considered along with the addition of two new descriptor subtypes: activity and progression applied to relapsing remitting and progressive MS phenotypes. In this way, the description of an individual patient's disease course is refined and provides temporal information about the ongoing disease process. There is still a lack of imaging and biological markers that would distinguish MS phenotypes and prognosticate the disease course on an individual patient's level, creating a pressing need for large collaborative research efforts in this field.
Collapse
Affiliation(s)
- Sylvia Klineova
- The CGD Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, New York 10029
| | - Fred D Lublin
- The CGD Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, New York 10029
| |
Collapse
|
30
|
Affiliation(s)
- Stephen C Krieger
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Fred D Lublin
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
31
|
Klineova S, Farber R, Friedman J, Farrell C, Lublin FD, Krieger S. Objective and subjective measures of dalfampridine efficacy in clinical practice. Mult Scler J Exp Transl Clin 2018; 4:2055217318786742. [PMID: 30090641 PMCID: PMC6077903 DOI: 10.1177/2055217318786742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/31/2018] [Indexed: 11/27/2022] Open
Abstract
Background Multiple sclerosis affects mobility in over 80% of patients. Dalfampridine is the only approved treatment for walking impairment in multiple sclerosis. We assessed dalfampridine utilization in our practice and investigated response using timed 25 foot walk (T25FW) improvement and a patient-reported ambulation inventory. Methods Chart review identified patients with multiple sclerosis for whom dalfampridine was prescribed. T25FW data were extracted from medical records. Participants completed a dalfampridine-specific version of the multiple sclerosis walking scale (dMSWS-12) to assess the qualitative impact of dalfampridine on ambulation. We evaluated two responder categories: liberally defined as any improvement in T25FW; and over 20% T25FW improvement. Results The dMSWS-12 questionnaire was completed by 39 patients. Eighteen patients (46%) did not show any T25FW improvement. Of the 21 patients (54%) with T25FW improvement, four patients (11%) showed improvement greater than 20%. Analysis of dMSWS-12 scores showed a median score of 40 (range 12–60). Eleven patients (28%) showed no improvement (dMSWS-12 score ≤36). In contrast to objective T25FW improvement (54%), 28 patients (72%) reported improvement in walking ability (dMSWS-12 score ≥37). Conclusion Our results suggest that T25FW alone might not be sufficient for response characterization and that adding patient-reported measures may further elucidate the therapeutic response.
Collapse
Affiliation(s)
- Sylvia Klineova
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Rebecca Farber
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Joshua Friedman
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Colleen Farrell
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Fred D Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Stephen Krieger
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| |
Collapse
|
32
|
Katz Sand I, Fabian MT, Telford R, Kraus TA, Chehade M, Masilamani M, Moran T, Farrell C, Ebel S, Cook LJ, Rose J, Lublin FD. Open-label, add-on trial of cetirizine for neuromyelitis optica. Neurol Neuroimmunol Neuroinflamm 2018; 5:e441. [PMID: 30426035 PMCID: PMC6201737 DOI: 10.1212/nxi.0000000000000441] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 12/12/2017] [Indexed: 12/19/2022]
Abstract
Objective This pilot study preliminarily examined the efficacy and tolerability of cetirizine as an add-on to standard therapy for neuromyelitis optica (NMO). Methods Eligible participants met the Wingerchuk 2006 diagnostic criteria or had a single typical episode along with positive NMO immunoglobulin G. After baseline clinical and laboratory assessments, participants began treatment with cetirizine 10 mg orally daily, in addition to their usual disease-modifying therapy for NMO, and continued for 1 year. The primary end point was the annualized relapse rate (ARR) while on the same disease-modifying therapy before starting cetirizine compared with after taking cetirizine. Additional end points included disability (Expanded Disability Status Scale [EDSS]), relapse severity, tolerability, especially with respect to drowsiness measured by the Epworth Sleepiness Scale (ESS), and laboratory parameters. Results The ARR before cetirizine was 0.4 ± 0.80 and after cetirizine was 0.1 ± 0.24 (p = 0.047). There was no statistically significant difference in the EDSS (mean 3.9 ± 2.18 before the start of the study and 3.2 ± 2.31 at the conclusion of the study, p = 0.500). The ESS remained fairly consistent throughout the study (mean 6.5 ± 5.33 at baseline and 6.9 ± 4.50 at month 12, p = 0.740). Laboratory studies were unrevealing. Conclusions In this pilot study, cetirizine was well tolerated, and the prespecified primary efficacy end point was satisfied. However, the open-label design and the small sample size of this pilot study preclude definitive conclusions. Further research is needed. Classification of evidence This study provides Class IV evidence that in patients with NMO, the addition of cetirizine to standard therapy is safe, well tolerated, and reduces relapses.
Collapse
Affiliation(s)
- Ilana Katz Sand
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Michelle T Fabian
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Russell Telford
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Thomas A Kraus
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Mirna Chehade
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Madhan Masilamani
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Thomas Moran
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Colleen Farrell
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Shelly Ebel
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Lawrence J Cook
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - John Rose
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| | - Fred D Lublin
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis (I.K.S., M.F., C.F., S.E., F.L.), Department of Neurology, Icahn School of Medicine at Mount Sinai, NY; Department of Pediatrics (R.T., L.C.), University of Utah, Salt Lake City; Drug Discovery Institute (T.A.K.), Mount Sinai Center for Eosinophilic Disorders (M.C.), Jaffe Food Allergy Institute (M.M.), Department of Pediatrics, and Department of Microbiology (T.M.), Icahn School of Medicine at Mount Sinai, NY; Department of Neurology (J.R.), University of Utah, Salt Lake City
| |
Collapse
|
33
|
Miller DH, Lublin FD, Sormani MP, Kappos L, Yaldizli Ö, Freedman MS, Cree BAC, Weiner HL, Lubetzki C, Hartung HP, Montalban X, Uitdehaag BMJ, MacManus DG, Yousry TA, Gandini Wheeler-Kingshott CAM, Li B, Putzki N, Merschhemke M, Häring DA, Wolinsky JS. Brain atrophy and disability worsening in primary progressive multiple sclerosis: insights from the INFORMS study. Ann Clin Transl Neurol 2018; 5:346-356. [PMID: 29560379 PMCID: PMC5846448 DOI: 10.1002/acn3.534] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 12/19/2017] [Accepted: 12/22/2017] [Indexed: 11/09/2022] Open
Abstract
Objective To investigate the relationship between brain volume and disability worsening over ≥3 years in the natural history of primary progressive multiple sclerosis using data from the placebo group of the INFORMS trial (n = 487; clinicaltrials.gov NCT00731692). Methods Magnetic resonance imaging scans were collected annually. Brain volume loss was determined using SIENA. Patients were stratified by baseline normalized brain volume after adjusting for demographic and disease-burden covariates. Results Baseline normalized brain volume was predictive of disability worsening: Risk of 3-month confirmed disability progression was reduced by 36% for high versus low baseline normalized brain volume (Cox's model hazard ratio 0.64, P = 0.0339; log-rank test: P = 0.0297). Moreover, on-study brain volume loss was significantly associated with disability worsening (P = 0.012) and was evident in patients with or without new lesions or relapses. Brain volume loss depended significantly on baseline T2 lesion volume (P < 0.0001). Despite low inflammatory activity at baseline (13% of patients had gadolinium-enhancing lesions) and throughout the study (mean 0.5 new/enlarging T2 lesions and 172 mm3 T2 lesion volume increase per year), baseline T2 lesion volume was substantial (mean 10 cm3). Lower normalized brain volume at baseline correlated with higher baseline T2 volume and older age (both P < 0.0001). Interpretation Baseline brain volume and the rate of ongoing brain atrophy are significantly associated with disability worsening in primary progressive multiple sclerosis. Brain volume loss is significantly related to baseline T2 lesion volume, but partially independent of new lesion activity, which might explain the limited efficacy of anti-inflammatory treatment.
Collapse
Affiliation(s)
- David H Miller
- Queen Square MS Centre UCL Institute of Neurology London UK
| | - Fred D Lublin
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis Icahn School of Medicine at Mount Sinai New York New York
| | - Maria Pia Sormani
- Biostatistics Unit Department of Health Sciences (DISSAL) University of Genoa Via Pastore 1 Genoa 16132 Italy
| | - Ludwig Kappos
- Departments of Medicine, Clinical Research, Biomedicine and Biomedical Engineering University Hospital University of Basel Basel Switzerland
| | - Özgür Yaldizli
- Department of Neurology University Hospital Basel Basel Switzerland
| | - Mark S Freedman
- The Ottawa Hospital Research Institute University of Ottawa Ottawa Ontario
| | - Bruce A C Cree
- Multiple Sclerosis Center University of California San Francisco California
| | - Howard L Weiner
- Brigham and Women's Hospital Harvard Medical School Boston Massachusetts
| | - Catherine Lubetzki
- Center of Clinical Investigation Salpêtrière Hospital APHP University Paris 6 Paris France
| | - Hans-Peter Hartung
- Department of Neurology Medical Faculty Heinrich-Heine University Düsseldorf Germany
| | | | | | | | - Tarek A Yousry
- Queen Square MS Centre UCL Institute of Neurology London UK
| | | | - Bingbing Li
- Novartis Pharmaceuticals Corporation East Hanover New Jersey
| | | | | | | | | |
Collapse
|
34
|
Lublin FD. Therapeutic approaches to secondary progressive multiple sclerosis. Mult Scler 2017. [DOI: 10.1177/1352458502008001188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- FD Lublin
- Corinne Guldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of
Medicine, One Gustave L. Levy Place, New York, NY 10029, USA
| |
Collapse
|
35
|
Lublin FD, Cofield SS, Cutter GR, Gustafson T, Krieger S, Narayana PA, Nelson F, Salter AR, Wolinsky JS. Long-term follow-up of a randomized study of combination interferon and glatiramer acetate in multiple sclerosis: Efficacy and safety results up to 7 years. Mult Scler Relat Disord 2017; 18:95-102. [PMID: 29141831 DOI: 10.1016/j.msard.2017.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/31/2017] [Accepted: 09/13/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND To report the long-term results of the blinded extension phase of the randomized, controlled study of the combined use of interferon beta-1a (IFN) 30μg IM weekly and glatiramer acetate (GA) 20mg daily compared to each agent alone in relapsing-remitting multiple sclerosis (RRMS). METHODS 1008 RRMS patients were followed on protocol until the last participant enrolled completed 3 years, allowing some subjects to be followed for up to 7 years. The primary endpoint was reduction in annualized relapse rate. Secondary outcomes included time to confirmed disability, Multiple Sclerosis Functional Composite (MSFC) score and MRI metrics. RESULTS Similar to the core study, combination IFN + GA was not superior to the better of the single agents (GA) in risk of relapse. Both the combination therapy and GA were significantly better than IFN in reducing the risk of relapse. The combination was not better than either agent alone in lessening confirmed EDSS worsening or change in MSFC. Also similar to the core result, the combination was superior to either agent alone in reducing new lesion activity, but the 3 year MRI result did not presage a clinical benefit over the extended observation interval. CONCLUSION Combining GA & IFN did not produce a significant clinical benefit over the entire study duration. The earlier effect on reducing MRI activity did not result in a later clinical advantage. The combination showed a sustained advantage in reducing disease activity free status.
Collapse
Affiliation(s)
- Fred D Lublin
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology & Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY, United States.
| | - Stacey S Cofield
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Gary R Cutter
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tarah Gustafson
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology & Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY, United States
| | - Stephen Krieger
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology & Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY, United States
| | - Ponnada A Narayana
- McGovern Medical School, Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Flavia Nelson
- McGovern Medical School, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Amber R Salter
- Department of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - Jerry S Wolinsky
- McGovern Medical School, Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, United States
| |
Collapse
|
36
|
Poretto V, Petracca M, Saiote C, Mormina E, Howard J, Miller A, Lublin FD, Inglese M. A composite measure to explore visual disability in primary progressive multiple sclerosis. Mult Scler J Exp Transl Clin 2017; 3:2055217317709620. [PMID: 28607759 PMCID: PMC5439656 DOI: 10.1177/2055217317709620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 04/20/2017] [Indexed: 11/17/2022] Open
Abstract
Background Optical coherence tomography (OCT) and magnetic resonance imaging (MRI) can provide complementary information on visual system damage in multiple sclerosis (MS). Objectives The objective of this paper is to determine whether a composite OCT/MRI score, reflecting cumulative damage along the entire visual pathway, can predict visual deficits in primary progressive multiple sclerosis (PPMS). Methods Twenty-five PPMS patients and 20 age-matched controls underwent neuro-ophthalmologic evaluation, spectral-domain OCT, and 3T brain MRI. Differences between groups were assessed by univariate general linear model and principal component analysis (PCA) grouped instrumental variables into main components. Linear regression analysis was used to assess the relationship between low-contrast visual acuity (LCVA), OCT/MRI-derived metrics and PCA-derived composite scores. Results PCA identified four main components explaining 80.69% of data variance. Considering each variable independently, LCVA 1.25% was significantly predicted by ganglion cell-inner plexiform layer (GCIPL) thickness, thalamic volume and optic radiation (OR) lesion volume (adjusted R2 0.328, p = 0.00004; adjusted R2 0.187, p = 0.002 and adjusted R2 0.180, p = 0.002). The PCA composite score of global visual pathway damage independently predicted both LCVA 1.25% (adjusted R2 value 0.361, p = 0.00001) and LCVA 2.50% (adjusted R2 value 0.323, p = 0.00003). Conclusion A multiparametric score represents a more comprehensive and effective tool to explain visual disability than a single instrumental metric in PPMS.
Collapse
Affiliation(s)
- Valentina Poretto
- Department of Neurosciences DNS, The Multiple Sclerosis Centre - Veneto Region (CeSMuV), University Hospital of Padua, Padua Italy
| | - Maria Petracca
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Catarina Saiote
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, USA
| | | | - Jonathan Howard
- Department of Neurology, Langone Medical Center, New York University, USA
| | - Aaron Miller
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Fred D Lublin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Matilde Inglese
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| |
Collapse
|
37
|
Petkau AJ, White RA, Ebers GC, Reder AT, Sibley WA, Lublin FD, Paty DW. Longitudinal analyses of the effects of neutralizing antibodies on interferon beta-1b in relapsing-remitting multiple sclerosis. Mult Scler 2016; 10:126-38. [PMID: 15124756 DOI: 10.1191/1352458504ms1004oa] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We have analysed data on exacerbation rates, Expanded Disability Status Scale (EDSS) scores, and lesion burdens using the results of two neutralizing antibody (NA B) assays (C PE and MxA) from the pivotal relapsing-remitting multiple sclerosis (MS) trial of interferon beta-1b (IFNB) with a longitudinal appro ach, where the influence of NA Bs in individual patients is assessed by comparing responses during NAB- positive and NA B-negative periods. There are apparent influences on exacerbation rate related to dose of IFNB, titer level, and duration of positivity. With the MxA assay, exacerbation rates after switching to NA B-positive status are estimated to be 28% higher [95% confidence interval (CI): (-15%, 92%)] and -2% higher [95% CI: (-21%, 21%)] on the low- and high-dose IFNB arms, respectively. When compared with all NA B-negative periods, exacerbation rates during NA B-positive periods are estimated to be 29% higher [95% C I: (0%, 67%)] and 18% higher [95% CI: (0%, 40%)] on the low- and high-dose IFNB arms, respectively. When NA B-positive patients again become NA B-negative, no evidence of increased exacerbation rates could then be demonstrated. More detailed exploratory analyses indicate that the effects are most evident in the approximately 20% of patients developing high titers. In these patients, the influence of NABs may be self-limited, as titers often diminish or NA Bs become undetectable with time.
Collapse
Affiliation(s)
- A John Petkau
- Department of Statistics, University of British Columbia, 333-6356 Agricultural Road, Vancouver, British Columbia, Canada V6T 1Z2.
| | | | | | | | | | | | | |
Collapse
|
38
|
Klineova S, Farber R, Saiote C, Farrell C, Delman BN, Tanenbaum LN, Friedman J, Inglese M, Lublin FD, Krieger S. Relationship between timed 25-foot walk and diffusion tensor imaging in multiple sclerosis. Mult Scler J Exp Transl Clin 2016; 2:2055217316655365. [PMID: 28607731 PMCID: PMC5433408 DOI: 10.1177/2055217316655365] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 05/24/2016] [Indexed: 11/16/2022] Open
Abstract
Objective/Background The majority of multiple sclerosis patients experience impaired walking ability, which
impacts quality of life. Timed 25-foot walk is commonly used to gauge gait impairment
but results can be broadly variable. Objective biological markers that correlate closely
with patients’ disability are needed. Diffusion tensor imaging, quantifying fiber tract
integrity, might provide such information. In this project we analyzed relationships
between timed 25-foot walk, conventional and diffusion tensor imaging magnetic resonance
imaging markers. Design/Methods A cohort of gait impaired multiple sclerosis patients underwent brain and cervical
spinal cord magnetic resonance imaging. Diffusion tensor imaging mean diffusivity and
fractional anisotropy were measured on the brain corticospinal tracts and spinal
restricted field of vision at C2/3. We analyzed relationships between baseline timed
25-foot walk, conventional and diffusion tensor imaging magnetic resonance imaging
markers. Results Multivariate linear regression analysis showed a statistically significant association
between several magnetic resonance imaging and diffusion tensor imaging metrics and
timed 25-foot walk: brain mean diffusivity corticospinal tracts (p = 0.004), brain
corticospinal tracts axial and radial diffusivity (P = 0.004 and 0.02), grey matter
volume (p = 0.05), white matter volume (p = 0.03) and normalized brain volume
(P = 0.01). The linear regression model containing mean diffusivity corticospinal tracts
and controlled for gait assistance was the best fit model (p = 0.004). Conclusions Our results suggest an association between diffusion tensor imaging metrics and gait
impairment, evidenced by brain mean diffusivity corticospinal tracts and timed 25-foot
walk.
Collapse
Affiliation(s)
- Sylvia Klineova
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, USA
| | - Rebecca Farber
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, USA
| | - Catarina Saiote
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Colleen Farrell
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, USA
| | - Bradley N Delman
- Department of Radiology, Icahn School of Medicine at Mount Sinai, USA
| | | | - Joshua Friedman
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, USA
| | - Matilde Inglese
- Department of Neurology, Icahn School of Medicine at Mount Sinai, USA
| | - Fred D Lublin
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, USA
| | - Stephen Krieger
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, USA
| |
Collapse
|
39
|
Affiliation(s)
| | - Fred D Lublin
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
40
|
Goodin DS, Reder AT, Bermel RA, Cutter GR, Fox RJ, John GR, Lublin FD, Lucchinetti CF, Miller AE, Pelletier D, Racke MK, Trapp BD, Vartanian T, Waubant E. Relapses in multiple sclerosis: Relationship to disability. Mult Scler Relat Disord 2015; 6:10-20. [PMID: 27063617 DOI: 10.1016/j.msard.2015.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 08/21/2015] [Accepted: 09/02/2015] [Indexed: 12/21/2022]
Abstract
Multiple sclerosis (MS) is a recurrent inflammatory disease of the central nervous system, which ultimately causes substantial disability in many patients. A key clinical feature of this disease is the occurrence of relapses, consisting of episodes of neurological dysfunction followed by periods of remission. This review considers in detail the importance of the occurrence of relapses to the ultimate course of MS and the impact of relap setreatment (both acutely and prophylactically) on the long-term outcome for individuals. The ultimate goal of therapy in MS is the reduction of long-term disability. Clinical trials in MS, however, typically only extend for a very short time period compared to the time it takes for disability to evolve. Consequently, short-term outcome measures that are associated with, and predict, future disability need to be identified. In this regard, not only are relapses a characteristic feature of MS, they have also been proven to be associated with the occurrence of long-term disability. Moreover, treatments that reduce the number and severity of these attacks improve the long-term prognosis.
Collapse
Affiliation(s)
- Douglas S Goodin
- Multiple Sclerosis Center, University of California, San Francisco Medical Center, San Francisco, CA, United States; Department of Neurology, University of California, San Francisco School of Medicine, San Francisco, CA, United States.
| | - Anthony T Reder
- Department of Neurology, The University of Chicago, Chicago, IL, United States
| | - Robert A Bermel
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, United States
| | - Gary R Cutter
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Gareth R John
- Multiple Sclerosis Research Laboratory, Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Friedman Brain Institute, New York, NY, United States; Department of Neurology, Mount Sinai School of Medicine, New York, NY, United States
| | - Fred D Lublin
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Aaron E Miller
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Daniel Pelletier
- Neuro-Immunology Division and Yale Multiple Sclerosis Center, Advanced Imaging in Multiple Sclerosis (AIMS) Laboratory, Yale University School of Medicine, New Haven, CT, United States
| | - Michael K Racke
- Department of Neurology, Wexner Medical Center at The Ohio State University, Columbus, OH, United States
| | - Bruce D Trapp
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Timothy Vartanian
- Judith Jaffe Multiple Sclerosis Center, New York-Presbyterian Hospital/Weill Cornell Medical Center, Weill Cornell Medical College, United States
| | - Emmanuelle Waubant
- UCSF Regional Pediatric MS Center, Race to Erase MS, San Francisco, CA, United States
| |
Collapse
|
41
|
Govindarajan KA, Datta S, Hasan KM, Choi S, Rahbar MH, Cofield SS, Cutter GR, Lublin FD, Wolinsky JS, Narayana PA. Effect of in-painting on cortical thickness measurements in multiple sclerosis: A large cohort study. Hum Brain Mapp 2015; 36:3749-3760. [PMID: 26096844 DOI: 10.1002/hbm.22875] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/27/2015] [Accepted: 06/01/2015] [Indexed: 11/06/2022] Open
Abstract
A comprehensive analysis of the effect of lesion in-painting on the estimation of cortical thickness using magnetic resonance imaging was performed on a large cohort of 918 relapsing-remitting multiple sclerosis patients who participated in a phase III multicenter clinical trial. An automatic lesion in-painting algorithm was developed and implemented. Cortical thickness was measured using the FreeSurfer pipeline with and without in-painting. The effect of in-painting was evaluated using FreeSurfer's paired analysis pipeline. Multivariate regression analysis was also performed with field strength and lesion load as additional factors. Overall, the estimated cortical thickness was different with in-painting than without. The effect of in-painting was observed to be region dependent, more significant in the left hemisphere compared to the right, was more prominent at 1.5 T relative to 3 T, and was greater at higher lesion volumes. Our results show that even for data acquired at 1.5 T in patients with high lesion load, the mean cortical thickness difference with and without in-painting is ∼2%. Based on these results, it appears that in-painting has only a small effect on the estimated regional and global cortical thickness. Hum Brain Mapp 36:3749-3760, 2015. © 2015 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Koushik A Govindarajan
- Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Texas
| | - Sushmita Datta
- Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Texas
| | - Khader M Hasan
- Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Texas
| | - Sangbum Choi
- Division of Clinical and Translational Sciences, Internal Medicine, University of Texas Medical School at Houston, Houston, Texas
| | - Mohammad H Rahbar
- Division of Clinical and Translational Sciences, Internal Medicine, University of Texas Medical School at Houston, Houston, Texas
| | - Stacey S Cofield
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Fred D Lublin
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, New York, New York
| | - Jerry S Wolinsky
- Department of Neurology, University of Texas Medical School at Houston, Houston, Texas
| | - Ponnada A Narayana
- Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, Texas
| | | | | |
Collapse
|
42
|
Lublin FD. Author response. Neurology 2015; 84:963. [PMID: 25905117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
|
43
|
Weisfeld-Adams JD, Katz Sand IB, Honce JM, Lublin FD. Differential diagnosis of Mendelian and mitochondrial disorders in patients with suspected multiple sclerosis. Brain 2015; 138:517-39. [PMID: 25636970 DOI: 10.1093/brain/awu397] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Several single gene disorders share clinical and radiologic characteristics with multiple sclerosis and have the potential to be overlooked in the differential diagnostic evaluation of both adult and paediatric patients with multiple sclerosis. This group includes lysosomal storage disorders, various mitochondrial diseases, other neurometabolic disorders, and several other miscellaneous disorders. Recognition of a single-gene disorder as causal for a patient's 'multiple sclerosis-like' phenotype is critically important for accurate direction of patient management, and evokes broader genetic counselling implications for affected families. Here we review single gene disorders that have the potential to mimic multiple sclerosis, provide an overview of clinical and investigational characteristics of each disorder, and present guidelines for when clinicians should suspect an underlying heritable disorder that requires diagnostic confirmation in a patient with a definite or probable diagnosis of multiple sclerosis.
Collapse
Affiliation(s)
- James D Weisfeld-Adams
- 1 Division of Clinical Genetics and Metabolism, Department of Paediatrics, University of Colorado School of Medicine, Aurora, Colorado 80045, USA 2 Inherited Metabolic Diseases Clinic, Children's Hospital Colorado, Aurora, Colorado 80045, USA 3 Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York 10029, USA
| | - Ilana B Katz Sand
- 4 Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York 10029, USA
| | - Justin M Honce
- 5 Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado 80045, USA
| | - Fred D Lublin
- 4 Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York 10029, USA
| |
Collapse
|
44
|
Datta S, Staewen TD, Cofield SS, Cutter GR, Lublin FD, Wolinsky JS, Narayana PA. Regional gray matter atrophy in relapsing remitting multiple sclerosis: baseline analysis of multi-center data. Mult Scler Relat Disord 2015; 4:124-36. [PMID: 25787188 PMCID: PMC4366621 DOI: 10.1016/j.msard.2015.01.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 11/25/2014] [Accepted: 01/12/2015] [Indexed: 11/28/2022]
Abstract
Regional gray matter (GM) atrophy in multiple sclerosis (MS) at disease onset and its temporal variation can provide objective information regarding disease evolution. An automated pipeline for estimating atrophy of various GM structures was developed using tensor based morphometry (TBM) and implemented on a multi-center sub-cohort of 1008 relapsing remitting MS (RRMS) patients enrolled in a Phase 3 clinical trial. Four hundred age and gender matched healthy controls were used for comparison. Using the analysis of covariance, atrophy differences between MS patients and healthy controls were assessed on a voxel-by-voxel analysis. Regional GM atrophy was observed in a number of deep GM structures that included thalamus, caudate nucleus, putamen, and cortical GM regions. General linear regression analysis was performed to analyze the effects of age, gender, and scanner field strength, and imaging sequence on the regional atrophy. Correlations between regional GM volumes and expanded disability status scale (EDSS) scores, disease duration (DD), T2 lesion load (T2 LL), T1 lesion load (T1 LL), and normalized cerebrospinal fluid (nCSF) were analyzed using Pearson׳s correlation coefficient. Thalamic atrophy observed in MS patients compared to healthy controls remained consistent within subgroups based on gender and scanner field strength. Weak correlations between thalamic volume and EDSS (r=-0.133; p<0.001) and DD (r=-0.098; p=0.003) were observed. Of all the structures, thalamic volume moderately correlated with T2 LL (r=-0.492; P-value<0.001), T1 LL (r=-0.473; P-value<0.001) and nCSF (r=-0.367; P-value<0.001).
Collapse
Affiliation(s)
- Sushmita Datta
- Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, 6431 Fannin, Houston, TX 77030, United States.
| | - Terrell D Staewen
- Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, 6431 Fannin, Houston, TX 77030, United States
| | - Stacy S Cofield
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Fred D Lublin
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Jerry S Wolinsky
- Department of Neurology University of Texas Medical School at Houston, 6431 Fannin, Houston, TX 77030, United States
| | - Ponnada A Narayana
- Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, 6431 Fannin, Houston, TX 77030, United States
| | | | | |
Collapse
|
45
|
Bhanushali MJ, Gustafson T, Powell S, Conwit RA, Wolinsky JS, Cutter GR, Lublin FD, Cofield SS. Recruitment of participants to a multiple sclerosis trial: the CombiRx experience. Clin Trials 2014; 11:159-66. [PMID: 24686106 DOI: 10.1177/1740774513517184] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND and purpose Participant recruitment is central to all clinical trials. Any delay in recruitment affects the completion and ultimate success of the trial. We report our experience with patient screening and randomization in CombiRx, which may inform the design of other trials. CombiRx was a multicenter, phase III, double-blind, randomized clinical trial comparing the combined use of interferon beta-1a and glatiramer acetate to either agent alone in patients with relapsing-remitting multiple sclerosis (RRMS). This trial was launched in January 2005 in 69 centers in the United States and Canada under a co-operative agreement with the National Institute of Neurological Disorders and Stroke (NINDS). The goal was to recruit 1000 patients over 1.5 years after a 6-month start-up period. Instead, the investigators required 4.25 years to enroll 1008 patients. METHODS During this trial, we assessed the effectiveness of various recruitment strategies, utility of rescreening prior screen failures, and potential factors and strategies used in study conduct, research, and infrastructure, all of which affected recruitment of participants and ultimately time to completion of CombiRx. We particularly were interested in the variability in time to site initiation between academic centers and private practice sites. RESULTS Physicians who were directly involved in the medical care of patients with RRMS were the primary source of patients recruited to CombiRx. A flexible study design that allowed for rescreening of the initial screen failures after a period of time was useful due to the relapsing/remitting course of the disease. Academic centers took longer to implement the trial than the private practice centers, but once sites were approved for enrollment, there was no important difference in the number of participants enrolled. LIMITATIONS The CombiRx trial was conducted during a period when multiple new medications were being tested, thus affecting the pace of recruitment and limiting ability to generalize our experiences. However, the lessons we learned about process are relevant. CONCLUSION Participants can be enrolled successfully in a clinical trial for RRMS, but factors affecting the time to achieve the requirements needed to start screening can be unpredictable and problematic. Prospective planning by the sponsors and investigators, use of central institutional review boards (IRBs), master trial agreements and secure remote desktop access to the trial database may expedite trial implementation and participant recruitment. A good scientific research question with flexible study design and active involvement of the clinicians are important factors driving recruitment. Clinical trials can be implemented successfully both in private practices and at academic centers, a consideration when selecting sites.
Collapse
Affiliation(s)
- Minal J Bhanushali
- aThe National Institute of Neurological Disorders and Stroke, National Institute of Health (NINDS/NIH), Rockville, MD, USA
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
BACKGROUND In 1996, the clinical course of multiple sclerosis (MS) was characterized as relapsing-remitting, primary progressive, secondary progressive or progressive relapsing. Since then, an increased understanding of MS and its pathology prompted a re-examination of these clinical phenotypes. Main recommendations of the 2013 revisions are provided herein. SUMMARY Clinically isolated syndrome has been added, and progressive relapsing MS has been eliminated, from the clinical course descriptions. All forms of MS should be further subcategorized as either active or non-active. Active MS is defined as the occurrence of clinical relapse or the presence of new T2 or gadolinium-enhancing lesions over a specified period of time, preferably at least one year. An additional subcategory for patients with progressive MS differentiates between those who have shown signs of disability progression over a given time period and those who have remained stable. The term 'worsening' is recommended to describe patients whose disease is advancing for any reason, whereas 'disease progression' should be reserved for those with progressive disease who are truly progressing (as opposed to worsening from a relapse). The term 'benign' should be used with caution as the course of MS can worsen at any time, even after many years of apparent stability. Key Messages: Newer characterizations of MS phenotypes include a consideration of disease activity (based on the clinical relapse rate and imaging findings) and disease progression. Accurate clinical course descriptions are useful for communication, prognostication, clinical trial design and to guide everyday clinical decision-making.
Collapse
Affiliation(s)
- Fred D Lublin
- Icahn School of Medicine, Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai, New York, N.Y., USA
| |
Collapse
|
47
|
Lublin FD, Bowen JD, Huddlestone J, Kremenchutzky M, Carpenter A, Corboy JR, Freedman MS, Krupp L, Paulo C, Hariri RJ, Fischkoff SA. Human placenta-derived cells (PDA-001) for the treatment of adults with multiple sclerosis: a randomized, placebo-controlled, multiple-dose study. Mult Scler Relat Disord 2014; 3:696-704. [PMID: 25891548 DOI: 10.1016/j.msard.2014.08.002] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/02/2014] [Accepted: 08/14/2014] [Indexed: 01/21/2023]
Abstract
BACKGROUND Infusion of PDA-001, a preparation of mesenchymal-like cells derived from full-term human placenta, is a new approach in the treatment of patients with multiple sclerosis. OBJECTIVE This safety study aimed to rule out the possibility of paradoxical exacerbation of disease activity by PDA-001 in patients with multiple sclerosis. METHODS This was a phase 1b, multicenter, randomized, double-blind, placebo-controlled, 2-dose ranging study including patients with relapsing-remitting multiple sclerosis or secondary progressive multiple sclerosis. The study was conducted at 6 sites in the United States and 2 sites in Canada. Patients were randomized 3:1 to receive 2 low-dose infusions of PDA-001 (150×10(6) cells) or placebo, given 1 week apart. After completing this cohort, subsequent patients received high-dose PDA-001 (600×10(6) cells) or placebo. Monthly brain magnetic resonance imaging scans were performed. The primary end point was ruling out the possibility of paradoxical worsening of MS disease activity. This was monitored using Cutter׳s rule (≥5 new gadolinium lesions on 2 consecutive scans) by brain magnetic resonance imaging on a monthly basis for six months and also the frequency of multiple sclerosis relapse. RESULTS Ten patients with relapsing-remitting multiple sclerosis and 6 with secondary progressive multiple sclerosis were randomly assigned to treatment: 6 to low-dose PDA-001, 6 to high-dose PDA-001, and 4 to placebo. No patient met Cutter׳s rule. One patient receiving high-dose PDA-001 had an increase in T2 and gadolinium lesions and in Expanded Disability Status Scale score during a multiple sclerosis flare 5 months after receiving PDA-001. No other patient had an increase in Expanded Disability Status Scale score>0.5, and most had stable or decreasing Expanded Disability Status Scale scores. With high-dose PDA-001, 1 patient experienced a grade 1 anaphylactoid reaction and 1 had grade 2 superficial thrombophlebitis. Other adverse events were mild to moderate and included headache, fatigue, infusion site reactions, and urinary tract infection. CONCLUSION PDA-001 infusions were safe and well tolerated in relapsing-remitting multiple sclerosis and secondary progressive multiple sclerosis patients. No paradoxical worsening of lesion counts was noted with either dose.
Collapse
Affiliation(s)
- Fred D Lublin
- Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1138, New York, NY 10029, United States.
| | - James D Bowen
- Swedish Neuroscience Institute, 1600 East Jefferson, Suite 205, Seattle, WA 98122, United States.
| | - John Huddlestone
- MultiCare Health System-Neuroscience Center of Washington, 915 6th Avenue, Suite 101 and 200, Tacoma, WA 98405, United States.
| | - Marcelo Kremenchutzky
- London Health Sciences Centre, University Hospital, Multiple Sclerosis Clinic, 7th Floor, 339 Windermere Road, PO Box 5339, London, ON, Canada N6A 5A5.
| | - Adam Carpenter
- University of Minnesota, Clinical Neuroscience Research Unit, 717 Delaware Street SE, Suite 246, Minneapolis, MN 55414, United States.
| | - John R Corboy
- University of Colorado Denver, 12631 E. 17th Avenue, Mail Stop B185, Room 5506, Aurora, CO 80045, United States.
| | - Mark S Freedman
- The Ottawa Hospital Multiple Sclerosis Clinic, 501 Smyth Road, Box 607, Ottawa, Ontario, Canada K1H 8L6.
| | - Lauren Krupp
- MS Comprehensive Care Center, MSC T12-020 SUNY, Stony Brook, NY 11794, United States.
| | - Corri Paulo
- Celgene Cellular Therapeutics, 7 Powderhorn Road, Warren, NJ 07059, United States.
| | - Robert J Hariri
- Celgene Cellular Therapeutics, 7 Powderhorn Road, Warren, NJ 07059, United States.
| | - Steven A Fischkoff
- Celgene Cellular Therapeutics, 7 Powderhorn Road, Warren, NJ 07059, United States.
| |
Collapse
|
48
|
Vidaurre OG, Haines JD, Katz Sand I, Adula KP, Huynh JL, McGraw CA, Zhang F, Varghese M, Sotirchos E, Bhargava P, Bandaru VVR, Pasinetti G, Zhang W, Inglese M, Calabresi PA, Wu G, Miller AE, Haughey NJ, Lublin FD, Casaccia P. Cerebrospinal fluid ceramides from patients with multiple sclerosis impair neuronal bioenergetics. Brain 2014; 137:2271-86. [PMID: 24893707 PMCID: PMC4164163 DOI: 10.1093/brain/awu139] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/20/2014] [Accepted: 04/06/2014] [Indexed: 11/14/2022] Open
Abstract
Axonal damage is a prominent cause of disability and yet its pathogenesis is incompletely understood. Using a xenogeneic system, here we define the bioenergetic changes induced in rat neurons by exposure to cerebrospinal fluid samples from patients with multiple sclerosis compared to control subjects. A first discovery cohort of cerebrospinal fluid from 13 patients with multiple sclerosis and 10 control subjects showed that acute exposure to cerebrospinal fluid from patients with multiple sclerosis induced oxidative stress and decreased expression of neuroprotective genes, while increasing expression of genes involved in lipid signalling and in the response to oxidative stress. Protracted exposure of neurons to stress led to neurotoxicity and bioenergetics failure after cerebrospinal fluid exposure and positively correlated with the levels of neurofilament light chain. These findings were validated using a second independent cohort of cerebrospinal fluid samples (eight patients with multiple sclerosis and eight control subjects), collected at a different centre. The toxic effect of cerebrospinal fluid on neurons was not attributable to differences in IgG content, glucose, lactate or glutamate levels or differences in cytokine levels. A lipidomic profiling approach led to the identification of increased levels of ceramide C16:0 and C24:0 in the cerebrospinal fluid from patients with multiple sclerosis. Exposure of cultured neurons to micelles composed of these ceramide species was sufficient to recapitulate the bioenergetic dysfunction and oxidative damage induced by exposure to cerebrospinal fluid from patients with multiple sclerosis. Therefore, our data suggest that C16:0 and C24:0 ceramides are enriched in the cerebrospinal fluid of patients with multiple sclerosis and are sufficient to induce neuronal mitochondrial dysfunction and axonal damage.
Collapse
Affiliation(s)
- Oscar G Vidaurre
- 1 Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffery D Haines
- 1 Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ilana Katz Sand
- 2 Corinne Goldsmith Dickinson Centre for MS, Mount Sinai Medical Centre, New York, NY 10029, USA
| | - Kadidia P Adula
- 1 Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jimmy L Huynh
- 1 Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Corey A McGraw
- 3 Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Centre, Bronx, NY, USA
| | - Fan Zhang
- 4 Bioinformatics Department, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Merina Varghese
- 5 Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elias Sotirchos
- 6 Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Pavan Bhargava
- 6 Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Giulio Pasinetti
- 5 Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Weijia Zhang
- 4 Bioinformatics Department, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matilde Inglese
- 7 Department of Neurology, Radiology and Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter A Calabresi
- 6 Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Gang Wu
- 8 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aaron E Miller
- 2 Corinne Goldsmith Dickinson Centre for MS, Mount Sinai Medical Centre, New York, NY 10029, USA
| | - Norman J Haughey
- 6 Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Fred D Lublin
- 2 Corinne Goldsmith Dickinson Centre for MS, Mount Sinai Medical Centre, New York, NY 10029, USA
| | - Patrizia Casaccia
- 1 Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
49
|
Lublin FD, Reingold SC, Cohen JA, Cutter GR, Sørensen PS, Thompson AJ, Wolinsky JS, Balcer LJ, Banwell B, Barkhof F, Bebo B, Calabresi PA, Clanet M, Comi G, Fox RJ, Freedman MS, Goodman AD, Inglese M, Kappos L, Kieseier BC, Lincoln JA, Lubetzki C, Miller AE, Montalban X, O'Connor PW, Petkau J, Pozzilli C, Rudick RA, Sormani MP, Stüve O, Waubant E, Polman CH. Defining the clinical course of multiple sclerosis: the 2013 revisions. Neurology 2014; 83:278-86. [PMID: 24871874 PMCID: PMC4117366 DOI: 10.1212/wnl.0000000000000560] [Citation(s) in RCA: 1925] [Impact Index Per Article: 192.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Accurate clinical course descriptions (phenotypes) of multiple sclerosis (MS) are important for communication, prognostication, design and recruitment of clinical trials, and treatment decision-making. Standardized descriptions published in 1996 based on a survey of international MS experts provided purely clinical phenotypes based on data and consensus at that time, but imaging and biological correlates were lacking. Increased understanding of MS and its pathology, coupled with general concern that the original descriptors may not adequately reflect more recently identified clinical aspects of the disease, prompted a re-examination of MS disease phenotypes by the International Advisory Committee on Clinical Trials of MS. While imaging and biological markers that might provide objective criteria for separating clinical phenotypes are lacking, we propose refined descriptors that include consideration of disease activity (based on clinical relapse rate and imaging findings) and disease progression. Strategies for future research to better define phenotypes are also outlined.
Collapse
Affiliation(s)
- Fred D Lublin
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Stephen C Reingold
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Jeffrey A Cohen
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Gary R Cutter
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Per Soelberg Sørensen
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Alan J Thompson
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Jerry S Wolinsky
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Laura J Balcer
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Brenda Banwell
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Frederik Barkhof
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Bruce Bebo
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Peter A Calabresi
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Michel Clanet
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Giancarlo Comi
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Robert J Fox
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Mark S Freedman
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Andrew D Goodman
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Matilde Inglese
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Ludwig Kappos
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Bernd C Kieseier
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - John A Lincoln
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Catherine Lubetzki
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Aaron E Miller
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Xavier Montalban
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Paul W O'Connor
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - John Petkau
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Carlo Pozzilli
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Richard A Rudick
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Maria Pia Sormani
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Olaf Stüve
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Emmanuelle Waubant
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| | - Chris H Polman
- From the Corinne Goldsmith Dickenson Center for Multiple Sclerosis (F.D.L., A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; Scientific and Clinical Review Associates, LLC (S.C.R.), Salisbury, CT; The Mellen Center for MS Treatment and Research (J.A.C., R.J.F., R.A.R.), Cleveland Clinic, OH; the Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; the Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, Copenhagen University Hospital Rigshospitalet, Denmark; University College London Institute of Neurology (A.J.T.), UK; the Department of Neurology (J.S.W., J.A.L.), University of Texas Health Sciences Center, Houston; the Department of Neurology (L.J.B.), New York University Langone Medical Center, New York; the Division of Neurology (B. Banwell), The Children's Hospital of Philadelphia, PA; the Departments of Radiology and Nuclear Medicine (F.B.) and Neurology (C.H.P.), VU Medical Center, Amsterdam, the Netherlands; Research Programs Department (B. Bebo), National Multiple Sclerosis Society, New York, NY; the Department of Neurology (P.A.C.), The Johns Hopkins Hospital, Baltimore, MD; Fédération de Neurologie (M.C.), CHU Hôpital Purpan, Toulouse, France; the Department of Neurology (G.C.), Scientific Institute San Raffaele, University Vita-Salute San Raffaele, Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Canada; the Department of Neurology (A.D.G.), University of Rochester Medical Center, NY; the Departments of Neurology, Radiology and Neuroscience (M.I.), Mount Sinai School of Medicine, New York, NY; the Department of Neurology (L.K.), University Hospital, Basel, Switzerland; the Department of Neurology (B.C.K.), Heinrich-Heine-University, Düsseldorf, Germany; the Department of Neurology (C.L.), Salpêtrière Hospital, UPMC, Paris, France; the Department of Neurology-Neuroimmunology (X.M.), Cemcat, Hospital Universitari Vall d'Hebron, Barcelona, Spain; the Division of
| |
Collapse
|
50
|
Calabresi PA, Radue EW, Goodin D, Jeffery D, Rammohan KW, Reder AT, Vollmer T, Agius MA, Kappos L, Stites T, Li B, Cappiello L, von Rosenstiel P, Lublin FD. Safety and efficacy of fingolimod in patients with relapsing-remitting multiple sclerosis (FREEDOMS II): a double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Neurol 2014; 13:545-56. [PMID: 24685276 DOI: 10.1016/s1474-4422(14)70049-3] [Citation(s) in RCA: 617] [Impact Index Per Article: 61.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Fingolimod has shown reductions in clinical and MRI disease activity in patients with relapsing-remitting multiple sclerosis. We further assessed the efficacy and safety of fingolimod in such patients. METHODS We did this placebo-controlled, double-blind phase 3 study predominantly in the USA (101 of 117 centres). Using a computer-generated sequence, we randomly allocated eligible patients-those aged 18-55 years with relapsing-remitting multiple sclerosis-to receive fingolimod 0·5 mg, fingolimod 1·25 mg, or placebo orally once daily (1:1:1; stratified by study centre). On Nov 12, 2009, all patients assigned to fingolimod 1·25 mg were switched to the 0·5 mg dose in a blinded manner after a review of data from other phase 3 trials and recommendation from the data and safety monitoring board, but were analysed as being in the 1·25 mg group in the primary outcome analysis. Our primary endpoint was annualised relapse rate at month 24, analysed by intention to treat. Secondary endpoints included percentage brain volume change (PBVC) from baseline and time-to-disability-progression confirmed at 3 months. This trial is registered with ClinicalTrilals.gov, number NCT00355134. FINDINGS Between June 30, 2006, and March 4, 2009, we enrolled and randomly allocated 1083 patients: 370 to fingolimod 1·25 mg, 358 to fingolimod 0·5 mg, and 355 to placebo. Mean annualised relapse rate was 0·40 (95% CI 0·34-0·48) in patients given placebo and 0·21 (0·17-0·25) in patients given fingolimod 0·5 mg: rate ratio 0·52 (95% CI 0·40-0·66; p<0·0001), corresponding to a reduction of 48% with fingolimod 0·5 mg versus placebo. Mean PBVC was -0·86 (SD 1·22) for fingolimod 0·5 mg versus -1·28 (1·50) for placebo (treatment difference -0·41, 95% CI -0·62 to -0·20; p=0·0002). We recorded no statistically significant between-group difference in confirmed disability progression (hazard rate 0·83 with fingolimod 0·5 mg vs placebo; 95% CI 0·61-1·12; p=0·227). Fingolimod 0·5 mg caused more of the following adverse events versus placebo: lymphopenia (27 [8%] patients vs 0 patients), increased alanine aminotransferase (29 [8%] vs six [2%]), herpes zoster infection (nine [3%] vs three [1%]), hypertension (32 [9%] vs 11 [3%]), first-dose bradycardia (five [1%] vs one [<0·5%]), and first-degree atrioventricular block (17 [5%] vs seven [2%]). 53 (15%) of 358 patients given fingolimod 0·5 mg and 45 (13%) of 355 patients given placebo had serious adverse events over 24 months, which included basal-cell carcinoma (ten [3%] patients vs two [1%] patients), macular oedema (three [1%] vs two [1%]), infections (11 [3%] vs four [1%]), and neoplasms (13 [4%] vs eight [2%]). INTERPRETATION Our findings expand knowledge of the safety profile of fingolimod and strengthen evidence for its beneficial effects on relapse rates in patients with relapsing-remitting multiple sclerosis. We saw no effect of fingolimod on disability progression. Our findings substantiate the beneficial profile of fingolimod as a disease-modifying agent in the management of patients with relapsing-remitting multiple sclerosis. FUNDING Novartis Pharma AG.
Collapse
Affiliation(s)
- Peter A Calabresi
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | - Douglas Goodin
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Douglas Jeffery
- The Multiple Sclerosis and Movement Disorders Center, Cornerstone Health Care, Winston-Salem, NC, USA
| | | | - Anthony T Reder
- Department of Neurology, University of Chicago Medical Center, Chicago, IL, USA
| | - Timothy Vollmer
- Department of Neurology, University of Colorado Denver, Aurora, CO, USA
| | - Mark A Agius
- Department of Neurology, University of California at Davis, Davis, CA, USA; Department of Veterans Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - Ludwig Kappos
- Department of Neurology, University Hospital, Basel, Switzerland
| | - Tracy Stites
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Bingbing Li
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Fred D Lublin
- Department of Neurology, Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Mount Sinai School of Medicine, NY, USA
| |
Collapse
|