Comparison of switching to 6-week dosing of natalizumab versus continuing with 4-week dosing in patients with relapsing-remitting multiple sclerosis (NOVA): a randomised, controlled, open-label, phase 3b trial

BACKGROUND

Treatment with natalizumab once every 4 weeks is approved for patients with relapsing-remitting multiple sclerosis, but is associated with a risk of progressive multifocal leukoencephalopathy. Switching to extended-interval dosing is associated with lower progressive multifocal leukoencephalopathy risk, but the efficacy of this approach is unclear. We aimed to assess the safety and efficacy of natalizumab once every 6 weeks compared with once every 4 weeks in patients with relapsing-remitting multiple sclerosis.

METHODS

We did a randomised, controlled, open-label, phase 3b trial (NOVA) at 89 multiple sclerosis centres across 11 countries in the Americas, Europe, and Western Pacific. Included participants were aged 18-60 years with relapsing-remitting multiple sclerosis and had been treated with intravenous natalizumab 300 mg once every 4 weeks with no relapses for at least 12 months before randomisation, with no missed doses in the previous 3 months. Participants were randomly assigned (1:1), using a randomisation sequence generated by the study funder and contract personnel with interactive response technology, to switch to natalizumab once every 6 weeks or continue with once every 4 weeks. The centralised MRI reader, independent neurology evaluation committee, site examining neurologists, site backup examining neurologists, and site examining technicians were masked to study group assignments. The primary endpoint was the number of new or newly enlarging T2 hyperintense lesions at week 72, assessed in all participants who received at least one dose of assigned treatment and had at least one postbaseline MRI, relapse, or neurological examination or efficacy assessment. Missing primary endpoint data were handled under prespecified primary and secondary estimands: the primary estimand included all data, regardless of whether participants remained on the assigned treatment; the secondary estimand classed all data obtained after treatment discontinuation or study withdrawal as missing. Safety was assessed in all participants who received at least one dose of study treatment. Study enrolment is closed and an open-label extension study is ongoing. This study is registered with EudraCT, 2018-002145-11, and ClinicalTrials.gov, NCT03689972.

FINDINGS

Between Dec 26, 2018, and Aug 30, 2019, 605 patients were assessed for eligibility and 499 were enrolled and assigned to receive natalizumab once every 6 weeks (n=251) or once every 4 weeks (n=248). After prespecified adjustments for missing data, mean numbers of new or newly enlarging T2 hyperintense lesions at week 72 were 0·20 (95% CI 0·07-0·63) in the once every 6 weeks group and 0·05 (0·01-0·22) in the once every 4 weeks group (mean lesion ratio 4·24 [95% CI 0·86-20·85]; p=0·076) under the primary estimand, and 0·31 (95% CI 0·12-0·82) and 0·06 (0·01-0·31; mean lesion ratio 4·93 [95% CI 1·05-23·20]; p=0·044) under the secondary estimand. Two participants in the once every 6 weeks group with extreme new or newly enlarging T2 hyperintense lesion numbers (≥25) contributed most of the excess lesions. Adverse events occurred in 194 (78%) of 250 participants in the once every 6 weeks group and 190 (77%) of 247 in the once every 4 weeks group, and serious adverse events occurred in 17 (7%) and 17 (7%), respectively. No deaths were reported. There was one case of asymptomatic progressive multifocal leukoencephalopathy (without clinical signs) in the once every 6 weeks group, and no cases in the once every 4 weeks group; 6 months after diagnosis, the participant was without increased disability and remained classified as asymptomatic.

INTERPRETATION

We found a numerical difference in the mean number of new or newly enlarging T2 hyperintense lesions at week 72 between the once every 6 weeks and once every 4 weeks groups, which reached significance under the secondary estimand, but interpretation of statistical differences (or absence thereof) is limited because disease activity in the once every 4 weeks group was lower than expected. The safety profiles of natalizumab once every 6 weeks and once every 4 weeks were similar. Although this trial was not powered to assess differences in risk of progressive multifocal leukoencephalopathy, the occurrence of the (asymptomatic) case underscores the importance of monitoring and risk factor consideration in all patients receiving natalizumab.

FUNDING

Biogen.

Sleep Quality in Neuromyelitis Optica Spectrum Disorder: A Systematic Review

BACKGROUND

This review summarizes the literature on sleep quality in neuromyelitis optica spectrum disorder (NMOSD) and discusses these findings in the context of current knowledge of sleep physiology.

METHODS

A literature search was performed using Ovid MEDLINE, Embase, and Scopus from inception to September 3, 2020. All included studies reported at least 1 measure of sleep quality in individuals with NMOSD. Pittsburgh Sleep Quality Index (PSQI) scores of individuals from 4 studies were compared with those from a data set of controls.

RESULTS

Thirteen studies (1041 individuals with NMOSD) were included in the review. Disturbed sleep was demonstrated across subjective metrics based on patient surveys and objective metrics such as polysomnography. An estimated 70% of individuals with NMOSD can be classified as poor sleepers. Standardized mean difference between PSQI scores of 183 individuals with NMOSD and those of 9284 controls was 0.72 (95% CI, 0.57-0.86; P < .001). Decreased sleep quality was significantly associated with decreased quality of life and increased anxiety, depression, and disability status. Sleep disturbances in NMOSD were similar in severity to those in multiple sclerosis.

CONCLUSIONS

Sleep disturbances are a major contributor to NMOSD disease burden and may arise from the disruption of sleep circuitry, in addition to physical and psychological complications. Multiple processes involved in sleep regulation may be affected, such as, but not limited to, neural circadian circuit disruption, direct effects of inflammation, aminergic projecting system abnormalities, glymphatic system impairment, and development of sleep disorders such as restless legs syndrome/sleep apnea. A better understanding of these mechanisms is necessary for developing effective therapies for NMOSD-associated sleep disturbances.

Modelling system of two insulin-glucose delays to achieve the dynamics of glucose changes

Background:

Due to the increased prevalence of diabetes and the irreparable complications of this disease, it is important to measure and monitor the blood glucose levels of diabetic patients. The only way to treat type 1 diabetes is monitoring insulin, and in this type of diabetes, insulin should be injected into the body in order to reduce the patient’s blood glucose as prescribed by the physician at certain times. In addition, the only way to treat type 2 diabetes is through diet and exercise daily.

Objective:

We aim to use an ordinary differential equation model with two-delays to control the rate of changes in blood glucose levels throughout the day, based on the amount of food that the person consumes.

Material and Methods:

In this analytical study, we extended an ODE model which is parameterized by data collected in this study to capture dynamics of glucose and insulin. We used global sensitivity analysis method to assess model robustness with respect to parameter perturbations.

Results:

Our results have shown that utilizing the dynamics of changes in blood glucose levels throughout the day can be used to prevent hypoglycemia and hyperglycemic in the diabetic patients.

Conclusion:

Dynamic modeling can help us to prevent hypoglycemia and hyperglycemia in the diabetic patients.

Cortical morphology predicts placebo response in multiple sclerosis

Despite significant insights into the neural mechanisms of acute placebo responses, less is known about longer-term placebo responses, such as those seen in clinical trials, or their interactions with brain disease. We examined brain correlates of placebo responses in a randomized trial of a then controversial and now disproved endovascular treatment for multiple sclerosis. Patients received either balloon or sham extracranial venoplasty and were followed for 48 weeks. Venoplasty had no therapeutic effect, but a subset of both venoplasty- and sham-treated patients reported a transient improvement in health-related quality of life, suggesting a placebo response. Placebo responders did not differ from non-responders in total MRI T2 lesion load, count or location, nor were there differences in normalized brain volume, regional grey or white matter volume or cortical thickness (CT). However, responders had higher lesion activity. Graph theoretical analysis of CT covariance showed that non-responders had a more small-world-like CT architecture. In non-responders, lesion load was inversely associated with CT in somatosensory, motor and association areas, precuneus, and insula, primarily in the right hemisphere. In responders, lesion load was unrelated to CT. The neuropathological process in MS may produce in some a cortical configuration less capable of generating sustained placebo responses.

Clinical characteristics and outcomes of multiple sclerosis patients with COVID-19 in Toronto, Canada

Objective

To report clinical characteristics and outcomes of people with multiple sclerosis (PwMS) who developed COVID-19 infection in Toronto, Canada.

Methods

Descriptive, retrospective, single-center study that included all known PwMS at the St. Michael's Hospital MS Clinic who had PCR-confirmed COVID-19 infection between March 2020 and May 2021.

Results

Of 7000 PwMS in our clinic, 80 (1.1%) tested positive for SARS-CoV-2. Fifty-four (67.5%) were on disease-modifying therapy (DMT) without over-representation of any single treatment. Seventy-one patients (88.8%) had mild symptoms, but nine (11.3%) were hospitalized and one 70-year-old male patient not on treatment died. Of those hospitalized, one-third were treated with ocrelizumab.

Conclusion

In Toronto, PwMS did not appear to have higher prevalence of COVID-19 infection compared to the general population, but disease severity may be affected by DMT use. Our findings add to the accumulating global data regarding COVID-19 infection in PwMS.

Clinical and MRI characteristics of multiple sclerosis in patients of Middle Eastern and North African ancestry residing in Ontario, Canada

BACKGROUND

Multiple sclerosis (MS) incidence is rising in traditionally low-burden regions, including the Middle East and North Africa (MENA).

OBJECTIVES

Our objective was to evaluate disease characteristics in MS patients of MENA descent (MENA-MS).

METHODS

MENA-MS patients and age- and sex-matched MS patients of European descent (EUR-MS) were identified through the MS Clinic Registry of St. Michael's Hospital in Toronto, Canada. Disease activity and severity were evaluated by the annualized relapse rate (ARR), magnetic resonance imaging (MRI) activity, change in the Expanded Disability Status Scale (EDSS), progression index (PI), and MS Severity Score (MSSS).

RESULTS

All MS patients within the registry identified to be of MENA origin (n = 192), and age- and sex-matched EUR-MS patients were included. Mean age was 42.9 years, 67% female. A total of 25% and 24% of EUR-MS and MENA-MS had progressive disease, with similar mean disease durations (11.5 and 11.4 years, respectively). Clinical and radiological disease activity (ARR, proportion with new/enlarging MRI lesions) was similar. MENA-MS showed greater disability progression over time (EDSS change = 0.24 vs. 0.06, p = 0.01), a higher MSSS (3.12 vs. 2.67, p = 0.04), and higher PI (0.34 vs. 0.27, p = 0.07).

CONCLUSION

MENA-MS patients demonstrate higher disease severity compared to EUR-MS patients, despite having similar inflammatory measures of disease activity, with disability progression in the absence of relapses. These observations illustrate the importance of the intersections of environmental, socioeconomic, and genetic determinants in optimizing individualized MS care.

Selective Colour Vision Deficits in Multiple Sclerosis at Different Temporal Stages

Multiple sclerosis (MS) without optic neuritis causes color-vision deficit but the evidence for selective color deficits in parvocellular-Red/Green (PC-RG) and koniocellular-Blue/Yellow (KC-BY) pathways is inconclusive. We investigated selective color-vision deficits at different MS stages. Thirty-one MS and twenty normal participants were tested for achromatic, red-green and blue-yellow sinewave-gratings (0.5 and 2 cycles-per-degree (cpd)) contrast orientation discrimination threshold. Red-green mean threshold at 0.5cpd in established-MS and blue-yellow mean threshold in all MS participants were abnormal. These findings show blue-yellow versus red-green color test is useful in differentiating MS chronicity, which helps to better understand the mechanism of colour-vision involvement in MS.

Safety and efficacy of venoplasty in MS: A randomized, double-blind, sham-controlled phase II trial

Objective

To determine the safety and efficacy of balloon vs sham venoplasty of narrowing of the extracranial jugular and azygos veins in multiple sclerosis (MS).

Methods

Patients with relapsing or progressive MS were screened using clinical and ultrasound criteria. After confirmation of >50% narrowing by venography, participants were randomized 1:1 to receive balloon or sham venoplasty of all stenoses and were followed for 48 weeks. Participants and research staff were blinded to intervention allocation. The primary safety outcome was the number of adverse events (AEs) during 48 weeks. The primary efficacy outcome was the change from baseline to week 48 in the patient-reported outcome MS Quality of Life–54 (MSQOL-54) questionnaire. Standardized clinical and MRI outcomes were also evaluated.

Results

One hundred four participants were randomized (55 sham; 49 venoplasty) and 103 completed 48 weeks of follow-up. Twenty-three sham and 21 venoplasty participants reported at least 1 AE; one sham (2%) and 5 (10%) venoplasty participants had a serious AE. The mean improvement in MSQOL-54 physical score was +1.3 (sham) and +1.4 (venoplasty) (p = 0.95); MSQOL-54 mental score was +1.2 (sham) and −0.8 (venoplasty) (p = 0.55).

Conclusions

Our data do not support the continued use of venoplasty of extracranial jugular and/or azygous venous narrowing to improve patient-reported outcomes, chronic MS symptoms, or the disease course of MS.

ClinicalTrials.gov identifier

NCT01864941.

Classification of evidence

This study provides Class I evidence that for patients with MS, balloon venoplasty of extracranial jugular and azygous veins is not beneficial in improving patient-reported, standardized clinical, or MRI outcomes.

Fluid-Attenuated Inversion Recovery Signal Intensity as a Predictor of Gadolinium Enhancement in Relapsing-Remitting Multiple Sclerosis

Background

Magnetic resonance imaging (MRI) is used to diagnose and monitor disease activity in relapsing-remitting multiple sclerosis (RRMS). The objective of this study was to explore the association of "ultrabright" axial fluid-attenuated inversion recovery (FLAIR) lesions with gadolinium enhancement in patients with RRMS using qualitative and quantitative approaches.

Methods

MRIs from patients with RRMS from 2010 to 2015 were reviewed. Two radiologists independently identified ultrabright lesions on axial FLAIR sequences. The contrast-to-noise ratio (CNR) was measured for ultrabright and control lesions.

Results

Of 301 lesions included in the study, 77 (26%) were identified by both radiologists as ultrabright. Interrater agreement was moderate (κ = 0.77, P < .001). Lesions identified by both radiologists as ultrabright demonstrated an association with gadolinium enhancement (χ²₁ = 30.8, P < .001) but were not associated with MRI magnet strength (χ²₁ = 0.24, P = .65). Higher CNR values were associated with gadolinium enhancement for 1.5-T studies (OR, 1.05; 95% CI, 1.02-1.07; P = .001) and 3-T studies (OR, 1.02; 95% CI, 1.02-1.03; P < .001). Diagnostic accuracy of the quantitative model was good for 1.5-T studies (area under the curve, 0.79; 95% CI, 0.68-0.9; P < .001) and 3-T studies (area under the curve, 0.78; 95% CI, 0.73-0.84; P < .001). Positive predictive value of 100% was obtained for CNR values of 92 for 1.5-T and 184 for 3-T studies.

Conclusions

Qualitatively and quantitatively identified ultrabright axial FLAIR lesions are significantly associated with gadolinium enhancement.

Multifocal leukoencephalopathy in cocaine users: a report of two cases and review of the literature

Background

Cocaine abuse is associated with several mechanisms of brain injury including ischemic, hemorrhagic and metabolic. Recently two case reports of leukoencephalopathy in cocaine users implicated a commonly used cocaine adulterant, levamisole. One well-documented adverse effect of levamisole, when used alone as antihelminthic or immunomodulatory drug, is multifocal inflammatory leukoencephalopathy. Therefore, immune mechanisms may also contribute to cocaine-induced brain injury.

Case presentations

Two cocaine users with multifocal leukoencephalopathy, treated with steroids and plasmapheresis, are described. The first is a 25-year-old man who presented with unilateral motor and sensory impairment progressing to bilateral deficits, dysphagia, dysarthria and confusion over several days. Serial MRI showed increasing abnormal FLAIR signal lesions with patchy restricted diffusion and heterogenous enhancement deep in the right and left hemispheres, including periventricular white matter as well as in the pons and cerebellar peduncle. The second patient is a 41-year-old woman who presented with confusion and impaired balance. MRI showed bilateral periventricular FLAIR lesions with scattered restricted diffusion and subtle gadolinium enhancement of some of the lesions. She initially stabilized with supportive care only, but after further cocaine use was re-admitted six weeks later with marked neurological deterioration and MRI showed prominent worsening of the lesions. Both patients received steroid and plasma exchange and showed substantial improvement clinically and on imaging, which was sustained during out-patient follow-up.

Conclusion

Multifocal leukoencephalopathy associated with cocaine use may have an inflammatory/immune basis, possibly related to levamisole contamination, at least in some patients. Three cases, including the present two, have been described wherein good neurological improvement was seen in association with steroid treatment. However, in the absence of appropriate clinical trials, it remains unknown whether immunotherapy is truly beneficial for these patients.

Multifocal leukoencephalopathy in cocaine users: a report of two cases and review of the literature

BACKGROUND

Cocaine abuse is associated with several mechanisms of brain injury including ischemic, hemorrhagic and metabolic. Recently two case reports of leukoencephalopathy in cocaine users implicated a commonly used cocaine adulterant, levamisole. One well-documented adverse effect of levamisole, when used alone as antihelminthic or immunomodulatory drug, is multifocal inflammatory leukoencephalopathy. Therefore, immune mechanisms may also contribute to cocaine-induced brain injury.

CASE PRESENTATIONS

Two cocaine users with multifocal leukoencephalopathy, treated with steroids and plasmapheresis, are described. The first is a 25-year-old man who presented with unilateral motor and sensory impairment progressing to bilateral deficits, dysphagia, dysarthria and confusion over several days. Serial MRI showed increasing abnormal FLAIR signal lesions with patchy restricted diffusion and heterogenous enhancement deep in the right and left hemispheres, including periventricular white matter as well as in the pons and cerebellar peduncle. The second patient is a 41-year-old woman who presented with confusion and impaired balance. MRI showed bilateral periventricular FLAIR lesions with scattered restricted diffusion and subtle gadolinium enhancement of some of the lesions. She initially stabilized with supportive care only, but after further cocaine use was re-admitted six weeks later with marked neurological deterioration and MRI showed prominent worsening of the lesions. Both patients received steroid and plasma exchange and showed substantial improvement clinically and on imaging, which was sustained during out-patient follow-up.

CONCLUSION

Multifocal leukoencephalopathy associated with cocaine use may have an inflammatory/immune basis, possibly related to levamisole contamination, at least in some patients. Three cases, including the present two, have been described wherein good neurological improvement was seen in association with steroid treatment. However, in the absence of appropriate clinical trials, it remains unknown whether immunotherapy is truly beneficial for these patients.

Thrombotic microangiopathy in Interferon Beta treated multiple sclerosis patients: Review of literature and report of two new cases

Beta interferons (IFN-β) were the first approved disease modifying therapies (DMTs) for relapsing-remitting multiple sclerosis (RRMS) and are still the most-widely prescribed medications for this disease. Despite good overall long-term safety data with prolonged use of this group of drugs, they can rarely cause serious and sometimes life threatening adverse effects. In this article we report two cases of thrombotic microangiopathy occurring during prolonged use of IFN-β and review the available literature on this topic.

Managing relapsing–remitting multiple sclerosis following first drug failure

SUMMARY IFN-β and glatiramer acetate are the usual first-line treatments for cases of relapsing–remitting multiple sclerosis. As both of these agents are only partially effective in controlling disease activity, ‘breakthrough’ disease is common. Deciding how much breakthrough constitutes a treatment failure necessitating a switch in therapy is now a common problem that most clinicians will encounter in practice. In this article we will discuss the approach to deciding when treatment failure occurs and the strategies that can be used to tackle this problem.

Case Report: Multiple Sclerosis and Amyotrophic Lateral Sclerosis

We present a case of concurrent multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS). Five other similar cases that have been reported in the literature are also reviewed. This rare and interesting case illustrates the importance of careful follow-up of patients with MS to avoid attributing every new neurologic symptom to the previously diagnosed disease and the maintenance of suspicion for unrelated emerging diseases.