Characterization of annual disease progression of multiple sclerosis patients: A population-based study

Background:

Previous research characterizing factors influencing multiple sclerosis (MS) disease progression has typically been based on time to disease milestones (Kaplan–Meier, Cox hazard regression, etc.). A limitation of these methods is the handling of the often large groups of patients not reaching the milestone.

Objective:

To characterize clinical factors influencing MS disease progression as annual transitions from each Expanded Disability Status Scale (EDSS).

Method:

The annual progression of 11,964 patients from the Swedish MS Registry was analysed with 10 multinomial logistic regressions, that is, one for transition from each full EDSS with explanatory variables age, sex, age at onset, time in current EDSS, highest prior EDSS, MS course and treatment.

Results:

All factors (except sex) investigated had statistically significant impacts on transitions from at least one EDSS. However, significance and size of the effect are dependent on the EDSS state of the patient. Greater age, longer time in a state, highest prior EDSS, having progressive MS and treatment had significant impacts, whereas age at onset had minor impact.

Conclusion:

Our study confirms that established factors associated with MS disease worsening in time to disease milestones also have impacts on annual progression. This approach adds granularity to what EDSS these factors have an influence.

Medicines Adaptive Pathways to Patients (MAPPs): A Story of International Collaboration Leading to Implementation

After nearly a decade of discussion, analysis, and development, the Medicines Adaptive Pathways to Patients (MAPPs) initiative is beginning to see acceptance from regulators, industry, patients, and payers, with the first live pilot project initiated under the guidance of the European Medicines Agency in 2014. Although it is a significant achievement to see the first asset being placed into human trials under an adaptive pathway, there is much to be learned regarding the multinational and multi-stakeholder effort that has driven the growing acceptance of MAPPs as a methodology and concept, as well as the need for continued and increasing international collaboration to foster the wider adoption of MAPPs. Changes in available science and technology, as well as a number of challenges in the current system, outlined in this paper, are transforming approaches to medicines development and approval. It is these challenges that have led directly to the groundbreaking MAPPs collaboration between the Massachusetts Institute of Technology Center for Biomedical Innovation's New Drug Development Paradigms Initiative, the EMA, patient, payer and health technology assessment groups, the European Federation of Pharmaceutical Industries and Associations, and the Innovative Medicines Initiative-a European public-private partnership. This article examines the development of MAPPs, from inception of the concept, to the establishment of this trans-Atlantic initiative, and examines challenges for the future.

From adaptive licensing to adaptive pathways: delivering a flexible life-span approach to bring new drugs to patients

The concept of adaptive licensing (AL) has met with considerable interest. Yet some remain skeptical about its feasibility. Others argue that the focus and name of AL should be broadened. Against this background of ongoing debate, we examine the environmental changes that will likely make adaptive pathways the preferred approach in the future. The key drivers include: growing patient demand for timely access to promising therapies, emerging science leading to fragmentation of treatment populations, rising payer influence on product accessibility, and pressure on pharma/investors to ensure sustainability of drug development. We also discuss a number of environmental changes that will enable an adaptive paradigm. A life‐span approach to bringing innovation to patients is expected to help address the perceived access vs. evidence trade‐off, help de‐risk drug development, and lead to better outcomes for patients.

Comparison of Stakeholder Metrics for Traditional and Adaptive Development and Licensing Approaches to Drug Development

This study evaluates whether an adaptive development and licensing approach to drug development, compared with approaches widely used today, might have tangible advantages across stakeholder groups, thereby facilitating the future adoption. Details involving actual and modeled clinical development and licensing programs for 3 case studies were used as inputs into a discounted cash flow spreadsheet model. Outputs included net present value and expected net present value, which are metrics considered as key incentives for pharmaceutical developers, and change in patient access over the product life and numbers of appropriately and inappropriately treated patients, which are metrics considered as key incentives for regulators, patients, and prescribers. Actual and modeled development programs were compared using an "adaptiveness" scoring algorithm. Generally, the more adaptive programs correlated with more favorable stakeholder outcomes. However, favorable outcomes may be overwhelmed in some cases, and the causative conditions and stakeholder reactions need to be defined.

Legal foundations of adaptive licensing

In April 2012, MIT's Center for Biomedical Innovation and the European Medicines Agency (EMA) cosponsored a workshop on legal foundations of adaptive pharmaceuticals licensing. Past and present attorneys from the US Food and Drug Administration (FDA), the EMA, and Health Sciences Agency Singapore (HSA) found that existing statutes provided authority for adaptive licensing (AL). By contrast, an attorney from Health Canada identified gaps in authority. Reimbursement during initial phases of adaptive approaches to licensing was deemed consistent with existing statutes in all jurisdictions.

Effects of breed and production system on lameness parameters in dairy cattle

The aim of the present study was to assess the effects of Holstein-Friesian (HF) and Norwegian (N) dairy cattle genotypes on lameness parameters in dairy cattle within different production systems over the first 2 lactations. Following calving, HF (n = 39) and N (n = 45) heifers were allocated to 1 of 3 systems of production (high level of concentrate, low level of concentrate, and grass-based). High- and low-concentrate animals were continuously housed indoors on a rotational system so that they spent similar amounts of time on slatted and solid concrete floors. Animals on the grass treatment grazed from spring to autumn in both years of the study, so that most animals on this treatment grazed from around peak to late lactation. Claw health was recorded in both hind claws of each animal at 4 observation periods during each lactation as follows: 1) -8 to 70 d postcalving, 2) 71 to 150 d postcalving, 3) 151 to 225 d postcalving, and 4) 226 to 364 d postcalving. Sole lesions, heel erosion, axial wall deviation, sole length of the right lateral hind claw (claw length), right heel width, and right lateral hind heel height were recorded as well as the presence of digital dermatitis. The N cows had lower (better) white line and total lesion scores than HF cows. Cows on the high- and low-concentrate treatments had better sole and total lesion scores than cows on the grass treatment. The HF cows had better locomotion scores than N cows. Breed and production system differences were observed with respect to claw conformation, including claw length, heel width, and heel height. Digital dermatitis was associated with worse sole lesion scores and interacted with production system to influence white line lesion scores and maximum heel erosion scores. This study shows that genetic, environmental, and infectious factors are associated with hoof pathologies in dairy cows.

DX-88 and HAE: a developmental perspective

An example of an approach to the developmental philosophy of novel recombinant products is explored by using the exemplar of Hereditary Angioedema (HAE). Plasma kallikrein is believed to be an important mediator of angioedema in patients with genetic deficiency of C1 esterase inhibitor (HAE patients). DX-88, a novel Kunitz domain produced by phage display (a powerful method of generating novel binders to potentially therapeutic targets), is a potent and selective inhibitor of plasma kallikrein which in early clinical studies demonstrates a useful efficacy/safety ratio in the treatment of acute attacks of HAE.

Voluntary guidance for the development of tissue-engineered products

Tissue Engineering is an emerging field of medical research in which there is tremendous activity. Many of these products rely on the use of a cellular component co-formulated with a natural or synthetic biomaterial. At this time, though, there are no consensus safety or efficacy standards for tissue-engineered products. We describe general approaches for assessment of the safety and efficacy of cell-based tissue-engineered products which will lead to reliable medical products for human use. This article provides a general summary of the factors that should be considered in the design and development of cell- and tissue-based products. Seven areas are considered: cell and tissue sourcing; cell and tissue characterization; biomaterials testing; quality assurance; quality control; and nonclinical testing and clinical evaluation. Factors relevant to these areas have been discussed to provide a set of recommendations on which development of products can be standardized. Where relevant, the discussion has been separated in each area to issues that are independent or dependent on cell source. Also, examples are provided of how these guidelines would be applied to two product types that represent somewhat extreme ends of the spectrum for tissue engineering applications. The first example is a product whose mechanism of action is to provide locally-acting structural repair or enhancement in vivo. The second example is a product whose mechanism of action involves systemically distributed physiologically or pharmacologically active products. In general, we have limited the discussion of product types to those that are implanted into the patient for relatively long periods of time. We believe that adoption of these voluntary guidelines would lead to products that are more consistent in quality and performance as well as more rapidly developed.

Immunoglobulin light and heavy chain isotypes in skin diseases: restricted distribution in bullous pemphigoid and linear IgA bullous dermatosis

To assess the heterogeneity of immunoglobulins involved in various skin diseases, direct and indirect immunofluorescence studies of skin biopsies and sera, respectively, for kappa and lambda light chains, were performed. The anti-basement membrane zone (anti-BMZ) antibodies of patients with bullous pemphigoid showed a predominance of kappa light chains, and patients with linear IgA bullous dermatosis showed a predominance of one light chain that was sometimes kappa and sometimes lambda. The bullous pemphigoid autoantibodies were then studied for IgG subclass distribution; a predominance of IgG4 was found. Although other explanations are possible, the light chain restriction in bullous pemphigoid most likely reflects heavy chain restriction and preferential association of heavy and light chain isotypes. The basis of the heavy chain restriction is not apparent. The light chain restriction in linear IgA bullous dermatosis may represent a restricted idiotypic repertoire.

Immunoglobulin light and heavy chain isotypes in skin diseases: restricted distribution in bullous pemphigoid and linear IgA bullous dermatosis

To assess the heterogeneity of immunoglobulins involved in various skin diseases, direct and indirect immunofluorescence studies of skin biopsies and sera, respectively, for kappa and lambda light chains, were performed. The anti-basement membrane zone (anti-BMZ) antibodies of patients with bullous pemphigoid showed a predominance of kappa light chains, and patients with linear IgA bullous dermatosis showed a predominance of one light chain that was sometimes kappa and sometimes lambda. The bullous pemphigoid autoantibodies were then studied for IgG subclass distribution; a predominance of IgG4 was found. Although other explanations are possible, the light chain restriction in bullous pemphigoid most likely reflects heavy chain restriction and preferential association of heavy and light chain isotypes. The basis of the heavy chain restriction is not apparent. The light chain restriction in linear IgA bullous dermatosis may represent a restricted idiotypic repertoire.

Characterization of antigens and antibody specificities involved in Heymann nephritis

The present study was conducted to determine if Fx1A, a renal cortical extract used to induce Heymann nephritis, contains nephritogenic antigens in addition to the brush border-derived glycoprotein gp 330. Of 26 Lewis rats immunized with Fx1A, 24 developed abnormal proteinuria (greater than 20 mg/24 hr) by wk 10, whereas of 15 rats immunized with a partially purified gp 330 preparation (MVH), only one developed proteinuria. Immunofluorescence studies showed that all Fx1A rats developed large, diffuse, granular deposits along the glomerular basement membrane which stained brightly for IgG and C3; only 11 of the 15 MVH rats had definite deposits; in most rats, they were small and stained only moderately for IgG and faintly or not at all for C3. The Fx1A and MVH rats developed comparable levels of antibodies to MVH (gp 330) before the onset of proteinuria in Fx1A rats, after which serum IgG and antibody levels declined. In contrast, antibodies against soluble Fx1A antigens appeared earlier and rose more rapidly in Fx1A than in MVH rats. Larger amounts of IgG could be eluted from the glomeruli of Fx1A rats than from MVH rats. Eluates from the Fx1A rats contained antibodies that reacted with gp 330 and also a 95 kd antigen; the latter reactivity was not demonstrated in eluates of MVH rats. Immunoprecipitation studies showed that both gp 330 and the 95 kd antigen are components of normal glomeruli. The results show that immunization with Fx1A produces a more severe form of Heymann nephritis than does gp 330, and that Fx1A contains at least one nephritogenic antigen in addition to gp 330.

Characterization of antigens and antibody specificities involved in Heymann nephritis

The present study was conducted to determine if Fx1A, a renal cortical extract used to induce Heymann nephritis, contains nephritogenic antigens in addition to the brush border-derived glycoprotein gp 330. Of 26 Lewis rats immunized with Fx1A, 24 developed abnormal proteinuria (greater than 20 mg/24 hr) by wk 10, whereas of 15 rats immunized with a partially purified gp 330 preparation (MVH), only one developed proteinuria. Immunofluorescence studies showed that all Fx1A rats developed large, diffuse, granular deposits along the glomerular basement membrane which stained brightly for IgG and C3; only 11 of the 15 MVH rats had definite deposits; in most rats, they were small and stained only moderately for IgG and faintly or not at all for C3. The Fx1A and MVH rats developed comparable levels of antibodies to MVH (gp 330) before the onset of proteinuria in Fx1A rats, after which serum IgG and antibody levels declined. In contrast, antibodies against soluble Fx1A antigens appeared earlier and rose more rapidly in Fx1A than in MVH rats. Larger amounts of IgG could be eluted from the glomeruli of Fx1A rats than from MVH rats. Eluates from the Fx1A rats contained antibodies that reacted with gp 330 and also a 95 kd antigen; the latter reactivity was not demonstrated in eluates of MVH rats. Immunoprecipitation studies showed that both gp 330 and the 95 kd antigen are components of normal glomeruli. The results show that immunization with Fx1A produces a more severe form of Heymann nephritis than does gp 330, and that Fx1A contains at least one nephritogenic antigen in addition to gp 330.

Studies with monoclonal antibodies against brush border antigens in Heymann nephritis

The authors have prepared and studied three murine monoclonal antibodies that are reactive with antigens in brush border regions of proximal renal tubules of rats. Two of the antibodies, 14C1 and AG3, were derived from mice immunized with Fx1A and the third, 4H6, from a mouse immunized with isolated glomeruli obtained from rats with Heymann nephritis. Immunohistochemical, immunoelectron microscopic, and immunochemical studies showed that the three antibodies recognized different antigens. The antibody 14C1 recognized the previously described nephritogenic glycoprotein, gp 330, in microvillar brush border preparations, and reacted with material present on podocyte cell surfaces of normal rat kidneys, especially in coated pits, as well as with material in the glomerular deposits of rats with Heymann nephritis. The antibody 4H6 recognized a 110-kilodalton microvillar antigen and reacted with material in the glycocalyx of podocytes of normal glomeruli, but showed only equivocal reactivity with material in the deposits in Heymann nephritis. AG3 failed to immunoprecipitate a distinctive antigen in microvillar preparations and did not react with the glomeruli of normal rats or of rats with Heymann nephritis. All three antibodies reacted with epithelial cells in the intestine, epididymis, and placenta; 4H6 also reacted with thin loops of Henle as well as with endothelial cells or other cells in lung, lymphoid tissue, liver, and spleen. The results demonstrate that not all brush border antigens participate in Heymann nephritis and confirm that an antigen (gp 330) involved in the formation of glomerular deposits in Heymann nephritis is normally present on podocyte surfaces, especially in coated pits, but is not present in extracellular sites.

Lymphocyte activation antigens. I. A monoclonal antibody, anti-Act I, defines a new late lymphocyte activation antigen

Lymphocyte activation entails a sequence of events identified by analyzing the time course of expression of various distinctive cell surface molecules on lymphocytes that appear early (before initiation of DNA synthesis), parallel with DNA synthesis and cellular proliferation, or late (after peak proliferation). In this study we present identification of a novel late lymphocyte activation antigen, Act I, utilizing a murine monoclonal antibody. Anti-Act I was identified in a fusion of NS1 with BALB/c spleen cells immunized with a human tetanus toxoid-reactive T lymphoblast line. Flow cytometry analysis shows that Act I antigen is present in markedly greater amounts on activated T and B lymphocytes than on resting, small peripheral blood lymphocytes. Act I expression by these lymphocytes is promoted by PHA, tetanus toxoid, or alloantigens and lags behind maximal thymidine incorporation by 1 to 2 days. Thymocytes can be triggered to express Act I antigen during maturation induced by PHA/T cell growth factor stimulation. In vitro, anti-Act I does not affect antigen- or lectin-stimulated T cell proliferation, T cell-mediated lymphocytotoxicity, or T cell growth factor-induced proliferation of T lymphoblasts. By immunoperoxidase analysis, Act I antigen is restricted to lymphoid tissue, staining many lymphocytes in the paracortex, germinal centers, and mantle zones of lymph nodes, tonsil, and spleen. By immunoprecipitation, the Act I antigen is a single band of 63,000 m.w. on reduced or nonreduced SDS gels. The distribution, size, time course, and functional correlates indicate that Act I is different from other known T cell activation markers detected with anti-Tac, OKT9, B3/25, OKT10, 4F2, CBL1, and anti-Ia-like antibodies. Although the function of Act I is still undetermined, it may serve as a useful marker of a late stage of activation in vitro and in vivo.

Lymphocyte activation antigens. I. A monoclonal antibody, anti-Act I, defines a new late lymphocyte activation antigen

Lymphocyte activation entails a sequence of events identified by analyzing the time course of expression of various distinctive cell surface molecules on lymphocytes that appear early (before initiation of DNA synthesis), parallel with DNA synthesis and cellular proliferation, or late (after peak proliferation). In this study we present identification of a novel late lymphocyte activation antigen, Act I, utilizing a murine monoclonal antibody. Anti-Act I was identified in a fusion of NS1 with BALB/c spleen cells immunized with a human tetanus toxoid-reactive T lymphoblast line. Flow cytometry analysis shows that Act I antigen is present in markedly greater amounts on activated T and B lymphocytes than on resting, small peripheral blood lymphocytes. Act I expression by these lymphocytes is promoted by PHA, tetanus toxoid, or alloantigens and lags behind maximal thymidine incorporation by 1 to 2 days. Thymocytes can be triggered to express Act I antigen during maturation induced by PHA/T cell growth factor stimulation. In vitro, anti-Act I does not affect antigen- or lectin-stimulated T cell proliferation, T cell-mediated lymphocytotoxicity, or T cell growth factor-induced proliferation of T lymphoblasts. By immunoperoxidase analysis, Act I antigen is restricted to lymphoid tissue, staining many lymphocytes in the paracortex, germinal centers, and mantle zones of lymph nodes, tonsil, and spleen. By immunoprecipitation, the Act I antigen is a single band of 63,000 m.w. on reduced or nonreduced SDS gels. The distribution, size, time course, and functional correlates indicate that Act I is different from other known T cell activation markers detected with anti-Tac, OKT9, B3/25, OKT10, 4F2, CBL1, and anti-Ia-like antibodies. Although the function of Act I is still undetermined, it may serve as a useful marker of a late stage of activation in vitro and in vivo.

Association of CSF IgG concentration and immunoglobulin allotype in multiple sclerosis and optic neuritis

The cerebrospinal fluid (CSF) and serum from 64 patients with multiple sclerosis (MS) and 47 patients with monosymptomatic optic neuritis (ON) were analyzed for the distribution of allotypic determinants on IgG and compared to similar samples from 51 patients with other neurological diseases (OND) as well as to serum samples from 97 healthy controls. The results indicate a significantly increased frequency of the haplotypes Gm a;g and Gm a,x;g among MS patients (P = 0.024) with an associated increase in relative risk for MS among individuals with the Gm a,(x);g haplotypes compared to those individuals without them (P = 0.014). Among MS patients, those with the Gm a,(x);g haplotypes had significantly higher CSF levels of IgG than those without (P = 0.016); levels of serum IgG did not covary with Gm haplotype. Two-way analysis of variance indicates that familial cases have significantly higher levels of CSF IgG than nonfamilial cases (P less than 0.001) and that familial cases with the Gm a,(x);g haplotypes have the highest CSF IgG levels (P less than 0.005). There was no correlation between Gm haplotype and CSF or serum IgG levels in patients with ON or OND. The allotype effects were independent of age at onset and duration of disease. In all patients, regardless of disease classification, the phenotypes found in serum samples were identical to those found in CSF samples. The data presented support the hypothesis that the etiology of MS has as one of its parameters an immunoregulatory/immunogenetic factor. The successful analysis of these various parameters will provide useful information not only about MS but also about general principles of human immune responsiveness.

Rabbit anti-human CSF IgG. I. Characterization of anti-idiotype antibodies produced against MS CSF and detection of cross-reactive idiotypes in several MS CSF

Serum from rabbits injected with IgG prepared from the CSF of patients with multiple sclerosis were rendered anti-idiotypic by adsorption on sequential columns of pooled human gamma-globulin, free light chains and free heavy chains. Adsorbed antisera precipitated between 15% and 45% of the autologous ligand and were inhibited by autologous CSF and serum and F(ab')2 fragments prepared from serum IgG. Idiotypic cross-reactivities were detected among the CSF IgG of several MS patients using three of these antisera. Two antisera demonstrated low levels of cross-reactivity with CSF IgG obtained from two of six heterologous MS patients. The third antiserum detected highly cross-reactive idiotypic determinants in the CSF IgG of two family members both having MS.

Rabbit anti-human CSF IgG. I. Characterization of anti-idiotype antibodies produced against MS CSF and detection of cross-reactive idiotypes in several MS CSF

Serum from rabbits injected with IgG prepared from the CSF of patients with multiple sclerosis were rendered anti-idiotypic by adsorption on sequential columns of pooled human gamma-globulin, free light chains and free heavy chains. Adsorbed antisera precipitated between 15% and 45% of the autologous ligand and were inhibited by autologous CSF and serum and F(ab')2 fragments prepared from serum IgG. Idiotypic cross-reactivities were detected among the CSF IgG of several MS patients using three of these antisera. Two antisera demonstrated low levels of cross-reactivity with CSF IgG obtained from two of six heterologous MS patients. The third antiserum detected highly cross-reactive idiotypic determinants in the CSF IgG of two family members both having MS.

Identification of a unique idiotype in cerebrospinal fluid and serum of a patient with multiple sclerosis

Anti-idiotypic antibodies were prepared in mouse ascites fluid against the CSF-IgG of a patient with multiple sclerosis. After adsorption with pooled human IgG, the ascites fluid antibodies precipitated 20% of labeled autologous CSF IgG. By using a competitive radioimmunoassay, less than one microgram of unlabeled CSF IgG produced 50% inhibition of binding autologous 125I-labeled CSF IgG, whereas 50 micrograms of normal HIgG was not inhibitory. The idiotype could be found in both serum and CSF IgG and persisted over a 5-year period. The absolute concentration of idiotype in the CSF varied somewhat but remained from 4 to 10 times greater than that of the serum. One of 14 heterologous MS CSF was found to contain small amounts of inhibitory protein; eight CSF from patients with other neurologic diseases did not contain the idiotype.

Identification of a unique idiotype in cerebrospinal fluid and serum of a patient with multiple sclerosis

Anti-idiotypic antibodies were prepared in mouse ascites fluid against the CSF-IgG of a patient with multiple sclerosis. After adsorption with pooled human IgG, the ascites fluid antibodies precipitated 20% of labeled autologous CSF IgG. By using a competitive radioimmunoassay, less than one microgram of unlabeled CSF IgG produced 50% inhibition of binding autologous 125I-labeled CSF IgG, whereas 50 micrograms of normal HIgG was not inhibitory. The idiotype could be found in both serum and CSF IgG and persisted over a 5-year period. The absolute concentration of idiotype in the CSF varied somewhat but remained from 4 to 10 times greater than that of the serum. One of 14 heterologous MS CSF was found to contain small amounts of inhibitory protein; eight CSF from patients with other neurologic diseases did not contain the idiotype.