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Miller AE. Dissemination in time as a requirement for diagnosis of multiple sclerosis: Time for a change? Mult Scler 2024; 30:479-482. [PMID: 38411037 DOI: 10.1177/13524585241233999] [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] [Indexed: 02/28/2024]
Abstract
The requirement to demonstrate dissemination in time (DIT) in order to diagnose multiple sclerosis (MS) has been enshrined in the literature since earliest efforts to establish diagnostic critera. However, various diagnostic criteria over the years, including the 2017 McDonald criteria, have inconsistently utilized this concept. This Viewpoint contends that current criteria for DIT are inadequate and sometimes inappropriate. It recommends continuing to consider DIT in the diagnosis of MS, but advocates utilizing all available information with high specificity for the disease, including the presence of large numbers of typical lesions, to make the diagnosis. This approach enables early initiation of disease-modifying treatment in situations with a favorable risk-benefit ratio.
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Affiliation(s)
- Aaron E Miller
- Aaron E Miller Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Corboy JR, Fox RJ, Kister I, Cutter GR, Morgan CJ, Seale R, Engebretson E, Gustafson T, Miller AE. Risk of new disease activity in patients with multiple sclerosis who continue or discontinue disease-modifying therapies (DISCOMS): a multicentre, randomised, single-blind, phase 4, non-inferiority trial. Lancet Neurol 2023; 22:568-577. [PMID: 37353277 DOI: 10.1016/s1474-4422(23)00154-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/15/2023] [Accepted: 04/14/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Multiple sclerosis typically has onset in young adults and new disease activity diminishes with age. Most clinical trials of disease-modifying therapies for multiple sclerosis have not enrolled individuals older than 55 years. Observational studies suggest that risk of return of disease activity after discontinuation of a disease-modifying therapies is greatest in younger patients with recent relapses or MRI activity. We aimed to determine whether risk of disease recurrence in older patients with no recent disease activity who discontinue disease-modifying therapy is increased compared to those who remain on disease-modifying therapy. METHODS DISCOMS was a multicentre, randomised, controlled, rater-blinded, phase 4, non-inferiority trial. Individuals with multiple sclerosis of any subtype, 55 years or older, with no relapse within the past 5 years or new MRI lesion in the past 3 years while continuously taking an approved disease-modifying therapy were enrolled at 19 multiple sclerosis centres in the USA. Participants were randomly assigned (1:1 by site) with an interactive response technology system to either continue or discontinue disease-modifying therapy. Relapse assessors and MRI readers were masked to patient assignment; patients and treating investigators were not masked. The primary outcome was percentage of individuals with a new disease event, defined as a multiple sclerosis relapse or a new or expanding T2 brain MRI lesion, over 2 years. We assessed whether discontinuation of disease-modifying therapy was non-inferior to continuation using a non-inferiority, intention-to-treat analysis of all randomly assigned patients, with a predefined non-inferiority margin of 8%. This trial is registered at ClinicalTrials.gov, NCT03073603, and is completed. FINDINGS 259 participants were enrolled between May 22, 2017, and Feb 3, 2020; 128 (49%) were assigned to the continue group and 131 (51%) to the discontinue group. Five participants were lost to follow-up (continue n=1, discontinue n=4). Six (4·7%) of 128 participants in the continue group and 16 (12·2%) of 131 in the discontinue group had a relapse or a new or expanding brain MRI lesion within 2 years. The difference in event rates was 7·5 percentage points (95% CI 0·6-15·0). Similar numbers of participants had adverse events (109 [85%] of 128 vs 104 [79%] of 131) and serious adverse events (20 [16%] vs 18 [14%]), but more adverse events (422 vs 347) and serious adverse events (40 vs 30) occurred in the discontinue group. The most common adverse events were upper respiratory infections (20 events in 19 [15%] participants in the continue group and 37 events in 30 [23%] participants in the discontinue group). Three participants in the continue group and four in the discontinue group had treatment-related adverse events, of which one in each group was a serious adverse event (multiple sclerosis relapse requiring admission to hospital). One participant in the continue group and two in the discontinue group died; no deaths were deemed to be related to treatment. INTERPRETATION We were unable to reject the null hypothesis and could not conclude whether disease-modifying therapy discontinuation is non-inferior to continuation in patients older than 55 years with multiple sclerosis and no recent relapse or new MRI activity. Discontinuation of disease-modifying therapy might be a reasonable option in patients older than 55 years who have stable multiple sclerosis, but might be associated with a small increased risk of new MRI activity. FUNDING Patient-Centered Outcomes Research Institute and the National Multiple Sclerosis Society.
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Affiliation(s)
- John R Corboy
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA
| | - Ilya Kister
- NYU MS Comprehensive Care Center, Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charity J Morgan
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rebecca Seale
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Eric Engebretson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Aaron E Miller
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Miller AE, Daiwile AP, Cadet JL. Sex-Dependent Alterations in the mRNA Expression of Enzymes Involved in Dopamine Synthesis and Breakdown After Methamphetamine Self-Administration. Neurotox Res 2022; 40:1464-1478. [PMID: 35834057 DOI: 10.1007/s12640-022-00545-z] [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: 05/27/2022] [Revised: 06/28/2022] [Accepted: 07/04/2022] [Indexed: 10/17/2022]
Abstract
Sex differences have been reported in methamphetamine (METH) use disorder in humans and in animal models of METH exposure. Specifically, animals that self-administer METH show sex-related dissimilarities in dopamine (DA) metabolism. To better understand the molecular bases for the differences in DA metabolism, we measured the levels of mRNAs of enzymes that catalyze DA synthesis and breakdown in the prefrontal cortex (PFC), nucleus accumbens (NAc), dorsal striatum (dSTR), and hippocampus (HIP) of rats that had self-administered METH. There were significant sex differences in control rats, with males having higher basal levels of Th in the PFC and dSTR, Ddc in the NAc, and MaoB in the HIP. In contrast, female controls showed higher basal levels of Comt in the HIP. Male and female METH SA rats also showed some distinct responses to the drug. Specifically, female METH rats exhibited increased expression of Ddc and MaoB, whereas male METH animals showed higher levels of Comt mRNA in the PFC compared to their respective controls. In the NAc, male METH rats displayed decreased Th and Ddc mRNA levels. Together, our results identified sex-dependent and region-specific changes in the mRNA expression of several enzymes involved in DA synthesis and breakdown in response to METH SA, with the majority of differences being observed in the mesocorticolimbic dopaminergic system. These findings are of significant translational importance providing further support for the inclusion of sex as an important variable when planning and evaluating therapeutic interventions against METH use disorder in human clinical studies.
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Affiliation(s)
- Aaron E Miller
- Molecular Neuropsychiatry Research Branch, NIDA Intramural Research Program, Baltimore, MD, 21224, USA
| | - Atul P Daiwile
- Molecular Neuropsychiatry Research Branch, NIDA Intramural Research Program, Baltimore, MD, 21224, USA
| | - Jean Lud Cadet
- Molecular Neuropsychiatry Research Branch, NIDA Intramural Research Program, Baltimore, MD, 21224, USA.
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Sprenger T, Kappos L, Sormani MP, Miller AE, Poole EM, Cavalier S, Wuerfel J. Effects of teriflunomide treatment on cognitive performance and brain volume in patients with relapsing multiple sclerosis: Post hoc analysis of the TEMSO core and extension studies. Mult Scler 2022; 28:1719-1728. [PMID: 35485424 PMCID: PMC9442776 DOI: 10.1177/13524585221089534] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: In post hoc analyses of Teriflunomide Multiple Sclerosis Oral study (TEMSO;
NCT00134563), teriflunomide 14 mg significantly reduced brain volume loss
(BVL) versus placebo in patients with relapsing multiple sclerosis (MS). Objective: In this post hoc analysis of TEMSO and its long-term extension (NCT00803049),
we examined the relationship between teriflunomide’s effects on BVL and
cognition. Methods: We analyzed data from 709 patients who received teriflunomide 14 mg in TEMSO
or its extension. The change in cognitive performance, assessed using the
Paced Auditory Serial Addition Test 3 (PASAT-3), was measured in subgroups
stratified by BVL over 2 years (least BVL: ⩽ 0.52%; intermediate BVL:
>0.52%–2.18%; most BVL: >2.18%). BVL, MRI lesions, and relapses over 2
years were evaluated as potential mediators of the effect of teriflunomide
on cognition. Results: Teriflunomide 14 mg significantly improved PASAT-3 Z-scores
versus placebo through year 2. In the least- and intermediate-BVL groups,
significant improvements in PASAT-3 Z-score were
demonstrated versus the most-BVL group over 3 years in the extension.
According to the mediation analysis, 44% of the teriflunomide effect on
cognition was due to effects on BVL at year 2. Conclusion: Teriflunomide improves cognition largely through its effects on BVL.
Accelerated BVL earlier in the disease course may predict cognitive
outcomes. ClinicalTrials.gov identifier: NCT00134563, NCT00803049
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Affiliation(s)
- Till Sprenger
- DKD Helios Klinik Wiesbaden, Deutsche Klinik für Diagnostik Wiesbaden, Germany/Neurologic Clinic and Policlinic and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital and University of Basel, Basel, Switzerland
| | - Ludwig Kappos
- Neurologic Clinic and Policlinic and Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital and University of Basel, Basel, Switzerland
| | - Maria Pia Sormani
- Biostatistics Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Aaron E Miller
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Steven Cavalier
- Sanofi, Cambridge, MA, USA/Steven Cavalier Consulting, LLC, Green Harbor, MA, USA
| | - Jens Wuerfel
- Medical Imaging Analysis Center (MIAC) AG and Department of Biomedical Engineering, University of Basel, Basel, Switzerland
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Abstract
Teriflunomide, a once daily, oral disease-modifying therapy, has demonstrated consistent efficacy, safety and tolerability in patients with relapsing forms of multiple sclerosis (MS) and with a first clinical episode suggestive of MS treated up to 12 years. This review is an update to a previous version that examined data from the teriflunomide core clinical development program and extension studies. Data have since become available from active comparator trials with other disease-modifying therapies, treatment-related changes in brain volume (analyzed using structural image evaluation using normalization of atrophy) and real-world evidence including patient-reported outcomes. Initial data on the potential antiviral effects of teriflunomide in patients with MS, including case reports of patients infected with the 2019 novel coronavirus (SARS-CoV-2), are also presented.
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Affiliation(s)
- Aaron E Miller
- Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA
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Cohen JA, Cameron MH, Goldman MD, Goodman AD, Miller AE, Rollins A, Llorens L, Patni R, Elfont R, Johnson R. A Phase 3, double-blind, placebo-controlled efficacy and safety study of ADS-5102 (Amantadine) extended-release capsules in people with multiple sclerosis and walking impairment. Mult Scler 2021; 28:817-830. [PMID: 34449295 PMCID: PMC8978468 DOI: 10.1177/13524585211035333] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: ADS-5102, a delayed-release, extended-release (DR/ER) amantadine, improved
walking speed in MS in a Phase 2 trial. Objective: The aim of this study was to present primary results of a Phase 3,
double-blind, ADS-5102 trial (INROADS) for walking speed. Methods: Adult participants with MS and walking impairment, not currently using
amantadine or dalfampridine, underwent 4-week placebo run-in before
randomization 1:1:1 to placebo, 137 or 274 mg/day ADS-5102 for 12 weeks.
Primary outcome was the proportion of responders (20% increase in Timed
25-Foot Walk (T25FW) speed) for 274 mg ADS-5102 versus placebo at end of
double-blind (Study Week 16). Additional measures included Timed Up and Go
(TUG), 2-Minute Walk Test (2MWT), and 12-item Multiple Sclerosis Walking
Scale (MSWS-12). Results: In total, 558 participants were randomized and received double-blind
treatment. Significantly more participants responded with 274 mg ADS-5102
(21.1%) versus placebo (11.3%). Mean T25FW speed also significantly improved
(0.19 ft/s) versus placebo (0.07 ft/s). Other measures were not significant
using prespecified hierarchical testing procedure. Adverse events led to
discontinuation for 3.8% (placebo), 6.4% (137 mg ADS-5102), and 20.5%
(274 mg ADS-5102). Conclusion: INROADS met its primary endpoint, showing a significantly greater proportion
of participants with meaningful improvement in walking speed for 274 mg
ADS-5102 versus placebo. Numeric dose response was seen for some secondary
efficacy outcomes and adverse events.
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Affiliation(s)
- Jeffrey A Cohen
- Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michelle H Cameron
- Veterans Affairs Portland Health Care System/Oregon Health & Science University, Portland, OR, USA
| | | | | | - Aaron E Miller
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne Rollins
- Adamas Pharmaceuticals, Inc., Emeryville, CA, USA
| | - Lily Llorens
- Adamas Pharmaceuticals, Inc., Emeryville, CA, USA
| | - Rajiv Patni
- Adamas Pharmaceuticals, Inc., Emeryville, CA, USA
| | | | - Reed Johnson
- Adamas Pharmaceuticals, Inc., Emeryville, CA, USA
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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.
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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
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Zhang Y, Staker E, Cutter G, Krieger S, Miller AE. Perceptions of risk and adherence to care in MS patients during the COVID-19 pandemic: A cross-sectional study. Mult Scler Relat Disord 2021; 50:102856. [PMID: 33662858 PMCID: PMC7899915 DOI: 10.1016/j.msard.2021.102856] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 10/12/2020] [Revised: 11/02/2020] [Accepted: 02/20/2021] [Indexed: 11/25/2022]
Abstract
Background The COVID-19 pandemic has raised concerns for increased risk of infection in patients with multiple sclerosis (MS) and disrupted their routine MS care. The aim of this study is to characterize the extent of MS patients’ perceptions of risk and adherence to care during the pandemic. Methods A survey was emailed to patients from a large MS center in New York City during the local peak of the pandemic to assess perceptions of infection risk and adherence to MS care including appointments, laboratory studies, MRIs, and taking disease-modifying therapies (DMT). Results 529 patients from the MS center responded to the survey during two weeks in April 2020. Patients collectively showed concern about becoming infected with COVID-19 (88%) and perceived a higher infection risk due of having MS (70%) and taking DMTs (68%). Patients frequently postponed appointments (41%), laboratory studies (46%), and MRIs (41%). Noncompliance with DMTs was less common (13%). Decisions to alter usual recommendations for care were made by the patient more often than by the provider regarding adherence to appointments (68%), laboratory studies (70%), MRI (67%), and DMT (65%). Degree of concern for infection was associated with adherence to appointments (p=0.020) and laboratory studies (p=0.016) but not with adherence to MRI and DMTs. Thirty-five patients reported being tested for COVID-19, of whom fourteen reported a positive test. Conclusion Patients with MS were highly concerned about becoming infected during the local peak of the COVID-19 pandemic. Behaviors that deviated from originally recommended MS care were common and often self-initiated, but patients were overall compliant with continuing DMTs.
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Affiliation(s)
- Yinan Zhang
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Erin Staker
- 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.
| | - Stephen Krieger
- 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.
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Miller AE, Chitnis T, Cohen BA, Costello K, Sicotte NL, Stacom R. Autologous Hematopoietic Stem Cell Transplant in Multiple Sclerosis: Recommendations of the National Multiple Sclerosis Society. JAMA Neurol 2021; 78:241-246. [PMID: 33104165 DOI: 10.1001/jamaneurol.2020.4025] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Autologous hematopoietic stem cell transplant (AHSCT) for multiple sclerosis has gained increasing interest in recent years. Despite the availability of many US Food and Drug Administration-approved disease-modifying therapies, some patients do not respond adequately and others may have very early aggressive disease that prompts consideration of alternative, highly effective, long-lasting therapy. The National Medical Advisory Committee of the National Multiple Sclerosis Society has reviewed recent literature on AHSCT for the purpose of making recommendations about its use based on current knowledge, as well as pointing out areas of controversy and issues requiring further research. Observations Studies on AHSCT have repeatedly demonstrated high efficacy and a durable outcome in people with relapsing multiple sclerosis. Recent studies have shown considerable improvement in the safety of the procedure, with much lower mortality rates than were reported earlier. Consensus is emerging about the characteristics of the best candidates for the procedure. Questions remain about the ideal protocol, particularly about the best conditioning regimen to be used to kill immune cells. Larger randomized clinical trials are needed to address the question of whether AHSCT has advantages over the most efficacious disease-modifying agents currently available. One such trial (Best Available Therapy Versus Autologous Hematopoietic Stem Cell Transplant for Multiple Sclerosis [BEAT-MS) is currently in progress. Conclusions and Relevance The National Multiple Sclerosis Society believes that AHSCT may be a useful treatment option for people with relapsing multiple sclerosis who demonstrate substantial breakthrough disease activity (ie, new inflammatory central nervous system lesions and/or clinical relapses) despite treatment with high-efficacy disease-modifying therapy or have contraindications to high-efficacy disease-modifying therapies. The best candidates are likely people younger than 50 years with shorter durations of disease (<10 years). The procedure should only be performed at centers with substantial experience and expertise. Ideally, recipients of the procedure should be entered into a single database, and further research is needed to establish ideal cell mobilization and immune-conditioning regimens.
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Affiliation(s)
- Aaron E Miller
- Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tanuja Chitnis
- Partners Multiple Sclerosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bruce A Cohen
- Davee Department of Neurology and Clinical Neurosciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Nancy L Sicotte
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, California
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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.
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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
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Miller AE, Olsson TP, Wolinsky JS, Comi G, Kappos L, Hu X, Xu X, Lublin AL, Truffinet P, Chavin J, Delhay JL, Benamor M, Purvis A, Freedman MS. Long-term safety and efficacy of teriflunomide in patients with relapsing multiple sclerosis: Results from the TOWER extension study. Mult Scler Relat Disord 2020; 46:102438. [DOI: 10.1016/j.msard.2020.102438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 10/23/2022]
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12
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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.
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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
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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.
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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.
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Bar-Or A, Grove RA, Tolson JM, Derosier FJ, Lopez MC, Kavanagh ST, Miller AE. Author response: Subcutaneous ofatumumab in patients with relapsing-remitting multiple sclerosis: The MIRROR study. Neurology 2019; 92:543. [PMID: 30858245 DOI: 10.1212/wnl.0000000000007085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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15
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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.
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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
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Klineova S, Brandstadter R, Fabian MT, Sand IK, Krieger S, Leavitt VM, Lewis C, Riley CS, Lublin F, Miller AE, Sumowski JF. Psychological resilience is linked to motor strength and gait endurance in early multiple sclerosis. Mult Scler 2019; 26:1111-1120. [PMID: 31172846 DOI: 10.1177/1352458519852725] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 12/11/2022]
Abstract
BACKGROUND Psychologically resilient persons persist despite obstacles and bounce back after adversity, leading to better outcomes in non-neurologic populations. It is unknown whether psychological resilience relates to objective functional outcomes in multiple sclerosis (MS). OBJECTIVE To determine whether psychological resilience explains differential objective cognitive and motor functioning in persons with early MS. METHODS Psychological resilience was assessed in 185 patients with early MS and 50 matched healthy controls with the Connors-Davidson Resilience Scale (CDRS-10). Subjects completed the MS Functional Composite (MSFC) and a comprehensive neurobehavioral evaluation. Correlations assessed links between CDRS-10 and MSFC, motor indices (Total, Fine Motor, Gross Motor), and cognitive indices (Total, Cognitive Efficiency, Memory). RESULTS Higher CDRS-10 among patients was linked to better MSFC and motor outcomes (but not cognition), with the most robust relationships for gross motor function (grip strength, gait endurance). Findings were independent of mood and fatigue. CDRS-10 was unrelated to MS disease burden. CDRS-10 was also specifically linked to motor outcomes in healthy controls. CONCLUSION Functional outcomes vary across persons with MS, even when disease burden and neurologic disability are low. These findings identify high psychological resilience as a non-disease-specific contributor to motor strength and endurance, which may explain differential outcomes across patients.
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Affiliation(s)
- Sylvia Klineova
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel Brandstadter
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michelle T 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
| | - Stephen Krieger
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Victoria M Leavitt
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Christina Lewis
- 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 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
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Comi G, Miller AE, Benamor M, Truffinet P, Poole EM, Freedman MS. Characterizing lymphocyte counts and infection rates with long-term teriflunomide treatment: Pooled analysis of clinical trials. Mult Scler 2019; 26:1083-1092. [PMID: 31172849 PMCID: PMC7412877 DOI: 10.1177/1352458519851981] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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] [Indexed: 11/30/2022]
Abstract
Background: In Phase 3 studies, teriflunomide reduced relapse rates and disability progression compared with placebo; however, decreases in lymphocyte counts were also observed. Objective: To describe the effect of long-term teriflunomide treatment on lymphocyte counts and infection rates among patients in pooled analyses of Phase 3 core and extension studies. Methods: Four randomized trials (TEMSO, TOWER, TENERE, and TOPIC) compared teriflunomide 7 mg or 14 mg treatment with either placebo and/or subcutaneous interferon (IFN) β-1a 44 µg in patients with relapsing forms of multiple sclerosis (MS) (or first clinical episode suggestive of MS in TOPIC). Results: In 1895, patients ever exposed to teriflunomide, mean (standard deviation) absolute lymphocyte counts declined from Week 0 (1.89 (0.59)) to Week 24 (1.67 (0.52)) and then remained stable thereafter. In the core plus extension studies (up to 10.7 years), 7.3% and 2.2% experienced Grade 1 and Grade 2 lymphopenia, respectively. Infections were reported in 56.9% of patients without lymphopenia, 60.9% with Grade 1 lymphopenia, and 54.8% with Grade 2 lymphopenia. Serious infections occurred in 3.7%, 4.3%, and 7.1%, respectively. Conclusion: Long-term risk of lymphopenia and infections in patients who continue to receive teriflunomide is low, demonstrating a limited impact on adaptive and innate immunity.
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Affiliation(s)
| | - Aaron E Miller
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Mark S Freedman
- University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Miller AE, Comi G, Benamor M, Truffinet P, Thangavelu K, Mandel M, Freedman MS. Impact limité à long terme du teriflunomide sur les numérations lymphocytaires et les infections dans les essais poolées TEMSO et TOWER princeps et d’extension. Rev Neurol (Paris) 2019. [DOI: 10.1016/j.neurol.2019.01.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Miller AE, Xu X, Macdonell R, Vucic S, Truffinet P, Benamor M, Thangavelu K, Freedman MS. Efficacy and safety of teriflunomide in Asian patients with relapsing forms of multiple sclerosis: A subgroup analysis of the phase 3 TOWER study. J Clin Neurosci 2018; 59:229-231. [PMID: 30348586 DOI: 10.1016/j.jocn.2018.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 01/18/2018] [Revised: 07/26/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Abstract
In the phase 3 TOWER (NCT00751881) study, teriflunomide 14 mg significantly reduced annualized relapse rate (ARR) and risk of 12-week confirmed disability worsening (12-w CDW) vs placebo in patients with relapsing forms of MS (RMS). The TOWER population included an appreciable proportion of Asian patients. Reductions in ARR and 12-w CDW associated with teriflunomide 14 mg were comparable between the Asian and overall populations, as were the rates for adverse events and serious adverse events, with no new or unexpected safety findings. These observations provide further evidence to support the clinical benefits and safety profile of teriflunomide in a broad range of patients with RMS.
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Affiliation(s)
- Aaron E Miller
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Xianhao Xu
- Department of Neurology, Beijing Hospital, Beijing, China.
| | | | - Steve Vucic
- Faculty of Medicine, University of Sydney, Sydney, Australia.
| | | | - Myriam Benamor
- Global Pharmacovigilance & Epidemiology, Sanofi, Chilly-Mazarin, France.
| | | | - Mark S Freedman
- Multiple Sclerosis Research Unit, Department of Neurology, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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Bar-Or A, Grove RA, Austin DJ, Tolson JM, VanMeter SA, Lewis EW, Derosier FJ, Lopez MC, Kavanagh ST, Miller AE, Sorensen PS. Subcutaneous ofatumumab in patients with relapsing-remitting multiple sclerosis: The MIRROR study. Neurology 2018; 90:e1805-e1814. [PMID: 29695594 PMCID: PMC5957306 DOI: 10.1212/wnl.0000000000005516] [Citation(s) in RCA: 131] [Impact Index Per Article: 21.8] [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: 07/11/2017] [Accepted: 02/23/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess dose-response effects of the anti-CD20 monoclonal antibody ofatumumab on efficacy and safety outcomes in a phase 2b double-blind study of relapsing forms of multiple sclerosis (RMS). METHODS Patients (n = 232) were randomized to ofatumumab 3, 30, or 60 mg every 12 weeks, ofatumumab 60 mg every 4 weeks, or placebo for a 24-week treatment period, with a primary endpoint of cumulative number of new gadolinium-enhancing lesions (per brain MRI) at week 12. Relapses and safety/tolerability were assessed, and CD19+ peripheral blood B-lymphocyte counts measured. Safety monitoring continued weeks 24 to 48 with subsequent individualized follow-up evaluating B-cell repletion. RESULTS The cumulative number of new lesions was reduced by 65% for all ofatumumab dose groups vs placebo (p < 0.001). Post hoc analysis (excluding weeks 1-4) estimated a ≥90% lesion reduction vs placebo (week 12) for all cumulative ofatumumab doses ≥30 mg/12 wk. Dose-dependent CD19 B-cell depletion was observed. Notably, complete depletion was not necessary for a robust treatment effect. The most common adverse event was injection-related reactions (52% ofatumumab, 15% placebo), mild to moderate severity in 97%, most commonly associated with the first dose and diminishing on subsequent dosing. CONCLUSION Imaging showed that all subcutaneous ofatumumab doses demonstrated efficacy (most robust: cumulative doses ≥30 mg/12 wk), with a safety profile consistent with existing ofatumumab data. This treatment effect also occurred with dosage regimens that only partially depleted circulating B cells. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for patients with RMS, ofatumumab decreases the number of new MRI gadolinium-enhancing lesions 12 weeks after treatment initiation.
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Affiliation(s)
- Amit Bar-Or
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA.
| | - Richard A Grove
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA
| | - Daren J Austin
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA
| | - Jerry M Tolson
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA
| | - Susan A VanMeter
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA
| | - Eric W Lewis
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA
| | - Frederick J Derosier
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA
| | - Monica C Lopez
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA
| | - Sarah T Kavanagh
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA
| | - Aaron E Miller
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA
| | - Per S Sorensen
- From the Department of Neurology (A.B.-O.), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Neuroimmunology Unit (A.B.-O.), Montreal Neurological Institute and Hospital, McGill University and McGill University Health Center, Quebec, Canada; Neurosciences Clinical Statistics (R.A.G.), Clinical Pharmacology (R.A.G., D.J.A.), and Modeling and Simulation (D.J.A.), GlaxoSmithKline, Uxbridge, Middlesex, UK; Neurosciences Therapy Area Unit (J.M.T., S.A.V., E.W.L., F.J.D., M.C.L., S.T.K.), SAVM (F.J.D., M.C.L.), Global Clinical Safety and Pharmacovigilance (E.W.L.), and Neurosciences Clinical Statistics (SecTK), GlaxoSmithKline, Research Triangle Park, NC; Department of Neurology (A.E.M.), Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY; and Danish Multiple Sclerosis Center (P.S.S.), Department of Neurology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark. Dr. Derosier is now at Clinical Development, Isis Pharmaceutical, Carlsbad, CA
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Affiliation(s)
- Aaron E Miller
- From the Corinne Goldsmith Dickinson Center for Multiple Sclerosis (A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; and MS Center and Division of Neuroimmunology and Neuroinfectious Diseases (P.A.C.), Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Peter A Calabresi
- From the Corinne Goldsmith Dickinson Center for Multiple Sclerosis (A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; and MS Center and Division of Neuroimmunology and Neuroinfectious Diseases (P.A.C.), Johns Hopkins University School of Medicine, Baltimore, MD
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Abstract
PURPOSE OF REVIEW This article reviews the reasons for discontinuation or switching of multiple sclerosis disease-modifying therapy as well as procedures that might mitigate risk to the patient under such circumstances. RECENT FINDINGS Recent review of the literature, as well as the author's extensive clinical experience, indicate that the discontinuation of multiple sclerosis disease-modifying therapies occurs for many reasons. Often one medication is stopped at the recommendation of the physician in order to switch to another medication. However, often the decision to discontinue medication is made by the patient. Unfortunately, in still other situations, treatment is stopped because of circumstances beyond the control of either patient or physician (eg, a loss of insurance coverage). Currently available data do not permit a conclusion about whether it is ever safe to discontinue disease-modifying therapy in a stable patient without the expectation of return of disease activity. SUMMARY Clinicians must help patients avoid unnecessary and undesirable cessation of disease-modifying therapy. While switches of therapy are often necessary, steps to minimize both adverse events and the risk of recurrent disease should be undertaken. Whether disease-modifying therapy can ever be purposely discontinued without incurring a significant risk of disease recurrence remains to be determined.
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Affiliation(s)
- Aaron E Miller
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Miller AE. Oral teriflunomide in the treatment of relapsing forms of multiple sclerosis: clinical evidence and long-term experience. Ther Adv Neurol Disord 2017; 10:381-396. [PMID: 29204190 PMCID: PMC5703103 DOI: 10.1177/1756285617722500] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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: 04/25/2017] [Accepted: 07/01/2017] [Indexed: 01/19/2023] Open
Abstract
Key objectives in the treatment of multiple sclerosis (MS) include prevention of relapses, a reduction in the accumulation of disability and slowing of the brain volume loss that occurs from the earliest stages of the disease. Teriflunomide, a once-daily, oral immunomodulatory therapy, has demonstrated efficacy across multiple measures of disease activity and worsening in patients with relapsing forms of MS and in those with a first clinical episode suggestive of MS. In this review, the latest evidence relating to the proposed mechanism of action of teriflunomide in MS is explored, including novel insights provided from the recently completed Teri-DYNAMIC study. Key clinical and magnetic resonance imaging data from the completed long-term extensions of the phase II and III (TEMSO, TOWER and TOPIC) studies are highlighted, and the long-term safety profile of teriflunomide, as evidenced by data from these extension studies, is presented. Although randomized clinical trials represent the highest level of evidence to support the use of therapeutic interventions, it is also important to understand the performance of a particular treatment in the real-world setting. In this regard, the results of the recently completed, global, phase IV Teri-PRO study are of particular interest and provide further insights into the benefits of teriflunomide treatment from the patient perspective. Collectively, the data presented in this review demonstrate a favorable benefit–risk profile for teriflunomide, thereby supporting its long-term use for the treatment of patients with relapsing forms of MS.
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Affiliation(s)
- Aaron E Miller
- Icahn School of Medicine at Mount Sinai, The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, 5 East 98th Street, Box 1138, New York, NY 10029, USA
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Macdonell R, Freedman MS, Xu X, Vucic S, Truffinet P, Benamor M, Thangavelu K, Miller AE. Efficacy and safety of teriflunomide in chinese patients with relapsing forms of ms: a subgroup analysis of the phase 3 tower study. J Neurol Psychiatry 2017. [DOI: 10.1136/jnnp-2017-316074.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Freedman MS, Wolinsky JS, Comi G, Kappos L, Olsson TP, Miller AE, Thangavelu K, Benamor M, Truffinet P, O'Connor PW. The efficacy of teriflunomide in patients who received prior disease-modifying treatments: Subgroup analyses of the teriflunomide phase 3 TEMSO and TOWER studies. Mult Scler 2017; 24:535-539. [PMID: 28304217 PMCID: PMC5891690 DOI: 10.1177/1352458517695468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [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] [Indexed: 11/16/2022]
Abstract
Teriflunomide is a once-daily oral immunomodulator approved for relapsing-remitting multiple sclerosis (MS). The objective of this post hoc analysis of the phase 3, pooled TEMSO (NCT00134563) and TOWER (NCT00751881) dataset is to evaluate the effect of teriflunomide treatment on annualised relapse rate and disability worsening across patient subgroups defined according to prior disease-modifying therapy exposure. This analysis provides further supportive evidence for a consistent effect of teriflunomide across a broad range of patients with relapsing MS, including patients who have used and discontinued other disease-modifying therapies.
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Affiliation(s)
- Mark S Freedman
- University of Ottawa and The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jerry S Wolinsky
- Multiple Sclerosis Research Group and MRI-Analysis Center, McGovern Medical School, UTHealth, Houston, TX, USA
| | - Giancarlo Comi
- Department of Neurology, University Vita-Salute San Raffaele, Milan, Italy
| | - Ludwig Kappos
- Neurology and Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Tomas P Olsson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Aaron E Miller
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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De Seze J, Miller AE, Kappos L, Comi G, Freedman MS, Oh J, Wolinsky JS. Données d’extension de l’étude TOPIC sur le tériflunomide chez des patients atteints de sclérose en plaques à un stade précoce : résultats cliniques jusqu’à 7 ans. Rev Neurol (Paris) 2017. [DOI: 10.1016/j.neurol.2017.01.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lebrun-Frénay C, Freedman MS, Miller AE, Comi G, Kappos L, Wolinsky JS. Données d’extension de l’étude TEMSO avec le tériflunomide : 10,5 ans de résultats cliniques. Rev Neurol (Paris) 2017. [DOI: 10.1016/j.neurol.2017.01.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Teriflunomide, a once-daily, oral disease-modifying therapy, has demonstrated efficacy in patients with relapsing forms of multiple sclerosis (MS) and patients with a first clinical episode suggestive of MS. As the only disease-modifying therapy with positive disability results in two Phase III trials, teriflunomide significantly slowed disability in patients with relapsing forms of MS. We highlight data from the Phase II study and the TEMSO, TOWER, TOPIC and TENERE teriflunomide studies. TEMSO MRI outcomes have been supported with Structural Image Evaluation Using Normalization of Atrophy analyses. We present data from long-term extensions of the Phase II study, TEMSO and TOWER, as well as results from patients who switched from other disease-modifying therapies to teriflunomide, patient-reported outcomes and supplementary measures of response.
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Affiliation(s)
- Aaron E Miller
- Icahn School of Medicine at Mount Sinai, New York City, NY, USA
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Freedman MS, Montalban X, Miller AE, Dive-Pouletty C, Hass S, Thangavelu K, Leist TP. Comparing outcomes from clinical studies of oral disease-modifying therapies (dimethyl fumarate, fingolimod, and teriflunomide) in relapsing MS: Assessing absolute differences using a number needed to treat analysis. Mult Scler Relat Disord 2016; 10:204-212. [DOI: 10.1016/j.msard.2016.10.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/30/2016] [Accepted: 10/31/2016] [Indexed: 11/16/2022]
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Zivadinov R, Cookfair DL, Krupp L, Miller AE, Lava N, Coyle PK, Goodman AD, Jubelt B, Lenihan M, Herbert J, Gottesman M, Snyder DH, Apatoff BR, Teter BE, Perel AB, Munschauer F, Weinstock-Guttman B. Factors associated with benign multiple sclerosis in the New York State MS Consortium (NYSMSC). BMC Neurol 2016; 16:102. [PMID: 27416843 PMCID: PMC4946222 DOI: 10.1186/s12883-016-0623-2] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 06/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This retrospective analysis explored prognostic factors associated with a benign multiple sclerosis (BMS) disease course at baseline and over the 4-year follow-up. METHODS Patients from the centralized New York State Multiple Sclerosis Consortium registry were classified as having BMS according to 3 different criteria centered on disease duration and disability. Additional analyses explored prognostic factors associated with BMS using the most conservative disability criteria (Expanded Disability Status Scale ≤2 and disease duration ≥10 years). RESULTS Among 6258 patients who fulfilled eligibility criteria, 19.8 % to 33.3 % were characterized as having BMS, at baseline depending on classification criteria used. Positive prognostic factors for BMS at baseline included female sex (p < 0.0001) and younger age at onset (p < 0.0001); negative prognostic factors included progressive-onset type of MS and African-American race. Of the 1237 BMS patients (per most conservative criteria), 742 were followed for a median of 4 years to explore effect of disease-modifying treatment (DMT) on benign status. DMT (p = 0.009) and longer disease duration (p = 0.007) were the only significant positive predictors of maintaining BMS at follow-up. The protective effect was stronger for patients taking DMT at both enrollment and follow-up (OR = 0.71; p = 0.006). CONCLUSIONS There is a need for development of more reliable prognostic indicators of BMS. Use of DMT was significantly associated with maintaining a benign disease state.
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Affiliation(s)
- Robert Zivadinov
- Buffalo Neuroimaging Analysis Center, Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA. .,Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA.
| | - Diane L Cookfair
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | - Lauren Krupp
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Aaron E Miller
- The Corinne Goldsmith Dickinson Center of Multiple Sclerosis, Mount Sinai School of Medicine, New York, NY, USA
| | - Neil Lava
- Department of Neurology, Albany Medical School, Multiple Sclerosis Center, Albany, NY, USA
| | - Patricia K Coyle
- Department of Neurology, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Andrew D Goodman
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Burk Jubelt
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Joseph Herbert
- Department of Neurology, NYU School of Medicine, New York, NY, USA
| | - Malcolm Gottesman
- Department of Neuroscience, Winthrop University Hospital, Mineola, NY, USA
| | - David H Snyder
- Department of Neurology, Weill Medical College of Cornell University, New York, NY, USA.,Department of Neurology, Albert Einstein College of Medicine, New York, NY, USA
| | | | - Barbara E Teter
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | | | - Frederick Munschauer
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | - Bianca Weinstock-Guttman
- Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
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Affiliation(s)
- Aaron E Miller
- From the Department of Neurology (A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Neurology (D.P.), Keck School of Medicine of USC, University of Southern California, Los Angeles.
| | - Daniel Pelletier
- From the Department of Neurology (A.E.M.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Neurology (D.P.), Keck School of Medicine of USC, University of Southern California, Los Angeles
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Affiliation(s)
- Aaron E Miller
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Tornatore C, Phillips JT, Khan O, Miller AE, Hughes M. Consensus opinion of US neurologists on practice patterns in RIS, CIS, and RRMS: Evolution of treatment practices. Neurol Clin Pract 2016; 6:329-338. [PMID: 27574570 DOI: 10.1212/cpj.0000000000000254] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW To assess current practice patterns of US neurologists in patients with radiologically isolated syndrome (RIS), clinically isolated syndrome (CIS), and relapsing-remitting multiple sclerosis (RRMS) using case-based Web surveys. RECENT FINDINGS We identified a total of 47 points of consensus (≥75% agreement) with regard to diagnosis, treatment, and monitoring of RIS, CIS, and RRMS. Current US treatment consensus patterns emphasize (1) MRI in multiple sclerosis (MS) diagnosis and subsequent treatment decisions, (2) treatment of early disease, (3) aggressive initial treatment of highly active MS, and (4) close patient monitoring for clinical response and adverse effects of disease-modifying drugs. SUMMARY These findings may offer insights into harmonizing MS care and represent the first steps in potentially establishing a more uniform approach to the treatment of patients with MS in the United States without compromising the need for individual treatment for each patient.
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Affiliation(s)
- Carlo Tornatore
- Medstar Georgetown University Hospital (CT), Washington, DC; Baylor Institute for Immunology Research (JTP), Dallas, TX; Wayne State University School of Medicine (OK), Detroit, MI; Icahn School of Medicine at Mount Sinai (AEM), New York, NY; and Infusion Communications (MH), Haddam, CT
| | - J Theodore Phillips
- Medstar Georgetown University Hospital (CT), Washington, DC; Baylor Institute for Immunology Research (JTP), Dallas, TX; Wayne State University School of Medicine (OK), Detroit, MI; Icahn School of Medicine at Mount Sinai (AEM), New York, NY; and Infusion Communications (MH), Haddam, CT
| | - Omar Khan
- Medstar Georgetown University Hospital (CT), Washington, DC; Baylor Institute for Immunology Research (JTP), Dallas, TX; Wayne State University School of Medicine (OK), Detroit, MI; Icahn School of Medicine at Mount Sinai (AEM), New York, NY; and Infusion Communications (MH), Haddam, CT
| | - Aaron E Miller
- Medstar Georgetown University Hospital (CT), Washington, DC; Baylor Institute for Immunology Research (JTP), Dallas, TX; Wayne State University School of Medicine (OK), Detroit, MI; Icahn School of Medicine at Mount Sinai (AEM), New York, NY; and Infusion Communications (MH), Haddam, CT
| | - Mark Hughes
- Medstar Georgetown University Hospital (CT), Washington, DC; Baylor Institute for Immunology Research (JTP), Dallas, TX; Wayne State University School of Medicine (OK), Detroit, MI; Icahn School of Medicine at Mount Sinai (AEM), New York, NY; and Infusion Communications (MH), Haddam, CT
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Mäurer M, Comi G, Freedman MS, Kappos L, Olsson TP, Wolinsky JS, Miller AE, Dive-Pouletty C, Bozzi S, O’Connor PW. Multiple sclerosis relapses are associated with increased fatigue and reduced health-related quality of life – A post hoc analysis of the TEMSO and TOWER studies. Mult Scler Relat Disord 2016; 7:33-40. [DOI: 10.1016/j.msard.2016.02.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 01/27/2016] [Accepted: 02/14/2016] [Indexed: 11/28/2022]
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O'Connor P, Comi G, Freedman MS, Miller AE, Kappos L, Bouchard JP, Lebrun-Frenay C, Mares J, Benamor M, Thangavelu K, Liang J, Truffinet P, Lawson VJ, Wolinsky JS. Long-term safety and efficacy of teriflunomide: Nine-year follow-up of the randomized TEMSO study. Neurology 2016; 86:920-30. [PMID: 26865517 PMCID: PMC4782117 DOI: 10.1212/wnl.0000000000002441] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [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: 03/27/2015] [Accepted: 11/16/2015] [Indexed: 11/15/2022] Open
Abstract
Objective: To report safety and efficacy outcomes from up to 9 years of treatment with teriflunomide in an extension (NCT00803049) of the pivotal phase 3 Teriflunomide Multiple Sclerosis Oral (TEMSO) trial (NCT00134563). Methods: A total of 742 patients entered the extension. Teriflunomide-treated patients continued the original dose; those previously receiving placebo were randomized 1:1 to teriflunomide 14 mg or 7 mg. Results: By June 2013, median (maximum) teriflunomide exposure exceeded 190 (325) weeks per patient; 468 patients (63%) remained on treatment. Teriflunomide was well-tolerated with continued exposure. The most common adverse events (AEs) matched those in the core study. In extension year 1, first AEs of transient liver enzyme increases or reversible hair thinning were generally attributable to patients switching from placebo to teriflunomide. Approximately 11% of patients discontinued treatment owing to AEs. Twenty percent of patients experienced serious AEs. There were 3 deaths unrelated to teriflunomide. Soon after the extension started, annualized relapse rates and gadolinium-enhancing T1 lesion counts fell in patients switching from placebo to teriflunomide, remaining low thereafter. Disability remained stable in all treatment groups (median Expanded Disability Status Scale score ≤2.5; probability of 12-week disability progression ≤0.48). Conclusions: In the TEMSO extension, safety observations were consistent with the core trial, with no new or unexpected AEs in patients receiving teriflunomide for up to 9 years. Disease activity decreased in patients switching from placebo and remained low in patients continuing on teriflunomide. Classification of evidence: This study provides Class III evidence that long-term treatment with teriflunomide is well-tolerated and efficacy of teriflunomide is maintained long-term.
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Affiliation(s)
- Paul O'Connor
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.).
| | - Giancarlo Comi
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Mark S Freedman
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Aaron E Miller
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Ludwig Kappos
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Jean-Pierre Bouchard
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Christine Lebrun-Frenay
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Jan Mares
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Myriam Benamor
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Karthinathan Thangavelu
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Jinjun Liang
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Philippe Truffinet
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Victoria J Lawson
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
| | - Jerry S Wolinsky
- From the University of Toronto (P.O.), Ontario, Canada; University Vita-Salute San Raffaele (G.C.), Milan, Italy; University of Ottawa and the Ottawa Hospital Research Institute (M.S.F.), Ontario, Canada; Icahn School of Medicine at Mount Sinai (A.E.M.), New York, NY; University Hospital Basel (L.K.), Switzerland; Laval University, Centre Hospitalier Universitaire de Québec (J.-P.B.), Québec, Canada; Hôpital Pasteur (C.L.-F.), Nice, France; Fakultni Nemocnice Olomouc (J.M.), Olomouc, Czech Republic; Sanofi Genzyme (M.B., P.T.), Chilly-Mazarin, France; Sanofi Genzyme (K.T.), Cambridge, MA; Sanofi (J.L.), Bridgewater, NJ; Fishawack Communications Ltd. (V.J.L.), Abingdon, UK; and University of Texas Health Science Center at Houston (J.S.W.)
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Comi G, Freedman MS, Kappos L, Olsson TP, Miller AE, Wolinsky JS, O'Connor PW, Benamor M, Dukovic D, Truffinet P, Leist TP. Pooled safety and tolerability data from four placebo-controlled teriflunomide studies and extensions. Mult Scler Relat Disord 2016; 5:97-104. [DOI: 10.1016/j.msard.2015.11.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 10/30/2015] [Accepted: 11/09/2015] [Indexed: 11/25/2022]
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Freedman MS, Wolinsky JS, Truffinet P, Comi G, Kappos L, Miller AE, Olsson TP, Benamor M, Chambers S, O'Connor PW. A randomized trial of teriflunomide added to glatiramer acetate in relapsing multiple sclerosis. Mult Scler J Exp Transl Clin 2015; 1:2055217315618687. [PMID: 28607708 PMCID: PMC5433345 DOI: 10.1177/2055217315618687] [Citation(s) in RCA: 3] [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] [Indexed: 11/29/2022] Open
Abstract
Background Teriflunomide is a once-daily oral immunomodulator for the treatment of relapsing−remitting MS. Objective To evaluate the safety and tolerability of teriflunomide as add-on therapy to a stable dose of glatiramer acetate (GA) in patients with relapsing forms of MS (RMS). Methods Phase II, randomized, double-blind, add-on, placebo-controlled study. The primary objective was to assess safety and tolerability; secondary objectives were to evaluate effects of treatment on disease activity assessed by MRI and relapse. Results Patients with RMS on GA (N = 123) were randomized 1:1:1 to receive teriflunomide 14 mg (n = 40), 7 mg (n = 42), or placebo (n = 41) for 24 weeks; 96 patients entered the 24-week extension, remaining on original treatment allocation. Teriflunomide was well tolerated over 48 weeks. The frequency of adverse events (AEs) was low across all groups; 5 (12.2%), 3 (7.1%), and 2 (5.0%) patients in the 14 mg, 7 mg, and placebo groups, respectively, discontinued treatment due to AEs. Teriflunomide reduced the number of T1-Gd lesions vs placebo (14 mg: 46.6% relative reduction, p = 0.1931; 7 mg: 64.0%: relative reduction, p = 0.0306). Conclusions Teriflunomide added to stable-dose GA had acceptable safety and tolerability, and reduced some MRI markers of disease activity compared with GA alone. NCT00475865 (core study); NCT00811395 (extension).
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Affiliation(s)
- M S Freedman
- University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - J S Wolinsky
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - P Truffinet
- Genzyme, a Sanofi company, Chilly-Mazarin, France
| | - G Comi
- University Vita-Salute San Raffaele, Milan, Italy
| | - L Kappos
- University Hospital Basel, Basel, Switzerland
| | - A E Miller
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - S Chambers
- Fishawack Communications Ltd, Abingdon, UK
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Abstract
PURPOSE The purpose was to summarize US prescribing information for teriflunomide in the treatment of patients with relapsing forms of multiple sclerosis (RMS), with reference to clinical efficacy and safety outcomes. METHODS In September 2012, the US Food and Drug Administration granted approval for the use of teriflunomide, 14 mg and 7 mg once daily, to treat RMS on the basis of the results of a Phase II study and the Phase III TEMSO (Teriflunomide Multiple Sclerosis Oral) trial. After recent updates to the prescribing information (October 2014), key findings from these and 2 other Phase III clinical trials, TOWER (Teriflunomide Oral in People With Relapsing Multiple Sclerosis) and TOPIC (Oral Teriflunomide for Patients with a First Clinical Episode Suggestive of Multiple Sclerosis), and practical considerations for physicians are summarized. FINDINGS Teriflunomide, 14 mg and 7 mg, significantly reduced mean number of unique active lesions on magnetic resonance imaging (MRI; P < 0.05 for both doses) in the Phase II study. In the TEMSO and TOWER studies, the 14-mg dose of teriflunomide significantly reduced annualized relapse rate (31% and 36% relative risk reduction compared with placebo, respectively; both P < 0.001) and risk of disability progression sustained for 12 weeks (hazard ratio vs placebo 0.70 and 0.69, respectively; both P < 0.05). The 7-mg dose significantly (P < 0.02) reduced annualized relapse rate in both studies, although the reduction in risk of disability progression was not statistically significant. Teriflunomide treatment was also associated with significant efficacy on MRI measures of disease activity in TEMSO; both doses significantly reduced total lesion volume and number of gadolinium-enhancing T1 lesions. TOPIC evaluated patients with a first clinical event consistent with acute demyelination and brain MRI lesions characteristic of multiple sclerosis. More patients were free of relapse in the teriflunomide 14-mg and 7-mg groups than in the placebo group (P < 0.05 for both comparisons). In safety data pooled from the 4 studies, adverse events occurring in ≥2% of patients and ≥2% higher than in the placebo group were headache, alanine aminotransferase increase, diarrhea, alopecia (hair thinning), nausea, paresthesia, arthralgia, neutropenia, and hypertension. Routine monitoring procedures before and on treatment are recommended to assess potential safety issues. Women of childbearing potential must use effective contraception and, in the event of pregnancy, undergo an accelerated elimination procedure to reduce plasma concentrations of teriflunomide. IMPLICATIONS Clinical evidence suggests that teriflunomide is an effective therapeutic choice for patients with RMS, both as an initial treatment and as an alternative for patients who may have experienced intolerance or inadequate response to a previous or current disease-modifying therapy.
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Affiliation(s)
- Aaron E Miller
- Icahn School of Medicine at Mount Sinai, New York, New York.
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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.
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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
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Klineova S, Mitiku N, Miller AE. Disease-modifying therapy for multiple sclerosis. Future Neurology 2015. [DOI: 10.2217/fnl.15.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Remarkable expansion of new diagnostic criteria and disease-modifying treatments for multiple sclerosis has occurred in the last two decades. Revision of diagnostic criteria and characterization of disease course has allowed earlier diagnosis and better characterization of individual patients. With the current treatment armamentarium in the USA offering 11 agents, patients can now benefit from increasingly individualized therapy. The therapeutic decision-making process has become more complex, with the availability of multiple medications. Relative efficacy, potentially severe adverse events, tolerability issues and patient's preferences must now all be considered so that increasingly disease management more frequently involves physicians with multiple sclerosis subspecialty expertise. This article aims to provide a clinically oriented and concise review of currently available, as well as emerging, disease-modifying treatment therapies in multiple sclerosis.
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Affiliation(s)
- Sylvia Klineova
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Suite 1138, New York, NY 10029, USA
| | - Nesanet Mitiku
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Suite 1138, New York, NY 10029, USA
| | - Aaron E Miller
- The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Suite 1138, New York, NY 10029, USA
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Freedman MS, Montalban X, Miller AE, Dive-Pouletty C, Leist TP. Assessing the Comparative Outcomes from Teriflunomide and Dimethyl Fumarate Studies in Relapsing Ms: Use of "Number Needed to Treat" Analysis. Value Health 2014; 17:A392. [PMID: 27200909 DOI: 10.1016/j.jval.2014.08.864] [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] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- M S Freedman
- University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - X Montalban
- Vall d'Hebron University Hospital, Barcelona, Spain
| | - A E Miller
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - T P Leist
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Miller AE, Wolinsky JS, Kappos L, Comi G, Freedman MS, Olsson TP, Bauer D, Benamor M, Truffinet P, O'Connor PW. Oral teriflunomide for patients with a first clinical episode suggestive of multiple sclerosis (TOPIC): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Neurol 2014; 13:977-86. [PMID: 25192851 DOI: 10.1016/s1474-4422(14)70191-7] [Citation(s) in RCA: 177] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Teriflunomide is a once-daily oral immunomodulator approved for the treatment of relapsing-remitting multiple sclerosis. We aimed to assess the efficacy and safety of teriflunomide in patients with a first clinical episode suggestive of multiple sclerosis. METHODS In this randomised, double-blind, placebo-controlled, parallel-group study, we enrolled patients aged 18-55 years with clinically isolated syndrome (defined as a neurological event consistent with demyelination, starting within 90 days of randomisation, and two or more T2-weighted MRI lesions ≥3 mm in diameter) from 112 centres (mostly hospitals) in 20 countries. Participants were randomly assigned (1:1:1) in a double-blind manner (by an interactive voice response system) to once-daily oral teriflunomide 14 mg, teriflunomide 7 mg, or placebo, for up to 108 weeks. Patients, staff administering the interventions, and outcome assessors were masked to treatment assignment. The primary endpoint was time to relapse (a new neurological abnormality separated by ≥30 days from a preceding clinical event, present for ≥24 h in the absence of fever or known infection), which defined conversion to clinically definite multiple sclerosis. The key secondary endpoint was time to relapse or new gadolinium-enhancing or T2 lesions on MRI, whichever occurred first. The primary outcome was analysed for the modified intention-to-treat population; safety analyses included all randomised patients who were exposed to the study drug, as treated. This trial is registered with ClinicalTrials.gov, number NCT00622700. FINDINGS Between Feb 13, 2008, and Aug 22, 2012, 618 patients were enrolled and randomly assigned to teriflunomide 14 mg (n=216), teriflunomide 7 mg (n=205), or placebo (n=197). Two patients in each of the teriflunomide groups did not receive the study drug, so the modified intention-to-treat population comprised 214 patients in the teriflunomide 14 mg group, 203 in the teriflunomide 7 mg group, and 197 in the placebo group. Compared with placebo, teriflunomide significantly reduced the risk of relapse defining clinically definite multiple sclerosis at the 14 mg dose (hazard ratio [HR] 0·574 [95% CI 0·379-0·869]; p=0·0087) and at the 7 mg dose (0·628 [0·416-0·949]; p=0·0271). Teriflunomide reduced the risk of relapse or a new MRI lesion compared with placebo at the 14 mg dose (HR 0·651 [95% CI 0·515-0·822]; p=0·0003) and at the 7 mg dose (0·686 [0·540-0·871]; p=0·0020). During the study, six patients who were randomly assigned to placebo accidently also received teriflunomide at some point: four received 7 mg and two received 14 mg. Therefore, the safety population comprised 216 patients on teriflunomide 14 mg, 207 on teriflunomide 7 mg, and 191 on placebo. Adverse events that occurred in at least 10% of patients in either teriflunomide group and with an incidence that was at least 2% higher than that with placebo were increased alanine aminotransferase (40 [19%] of 216 patients in the 14 mg group, 36 [17%] of 207 in the 7 mg group vs 27 [14%] of 191 in the placebo group), hair thinning (25 [12%] and 12 [6%] vs 15 [8%]), diarrhoea (23 [11%] and 28 [14%] vs 12 [6%]), paraesthesia (22 [10%] and 11 [5%] vs 10 [5%]), and upper respiratory tract infection (20 [9%] and 23 [11%] vs 14 [7%]). The most common serious adverse event was an increase in alanine aminotransferase (four [2%] and five [2%] vs three [2%]). INTERPRETATION TOPIC is to our knowledge the first study to report benefits of an available oral disease-modifying therapy in patients with early multiple sclerosis. These results extend the stages of multiple sclerosis in which teriflunomide shows a beneficial effect. FUNDING Genzyme, a Sanofi company.
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Affiliation(s)
- Aaron E Miller
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Jerry S Wolinsky
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | | | - Mark S Freedman
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
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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.
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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
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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: 1945] [Impact Index Per Article: 194.5] [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.
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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
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Abstract
Secondary progressive multiple sclerosis (MS) is typically defined as deterioration independent of relapses for ≥ 6 months following an initial relapsing-remitting course; however, this definition is not always easily applied in clinical practice and the declaration of the change in clinical phenotype is often delayed. To identify the length of time required to re-classify relapsing-remitting MS (RRMS) patients whom have clinically transitioned to secondary progressive MS (SPMS) in clinical practice. We reviewed 123 patients with long-term follow-up and identified a sub-group whom transitioned from RRMS to SPMS, then characterized this transition period. There were 14/20 patients who transitioned during the follow-up period that had visits with uncertainty related to the clinical phenotype characterized by possible, but not definitive progression. The mean duration of this period of uncertainty was 2.9 ± 0.8 years. A period of diagnostic uncertainty regarding the transition from RRMS to SPMS existed in many of our patients. Potential reasons included the subtle nature of early progressive disease and caution in applying a progressive label, in light of the lack of evidence-based treatments as well as third-party payer concerns. Delay in definitive identification of an SPMS phenotype has a variety of implications related to patient care and research.
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Confavreux C, O'Connor P, Comi G, Freedman MS, Miller AE, Olsson TP, Wolinsky JS, Bagulho T, Delhay JL, Dukovic D, Truffinet P, Kappos L. Oral teriflunomide for patients with relapsing multiple sclerosis (TOWER): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Neurol 2014; 13:247-56. [PMID: 24461574 DOI: 10.1016/s1474-4422(13)70308-9] [Citation(s) in RCA: 393] [Impact Index Per Article: 39.3] [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: 12/13/2022]
Abstract
BACKGROUND Teriflunomide is an oral disease-modifying therapy approved for treatment of relapsing or relapsing-remitting multiple sclerosis. We aimed to provide further evidence for the safety and efficacy of teriflunomide in patients with relapsing multiple sclerosis. METHODS This international, randomised, double-blind, placebo-controlled, phase 3 study enrolled adults aged 18-55 years with relapsing multiple sclerosis, one or more relapse in the previous 12 months or two or more in the previous 24 months but no relapse in the previous 30 days, and an Expanded Disability Status Scale (EDSS) score of 5.5 points or less. Patients were recruited from 189 sites in 26 countries and randomly assigned (1:1:1) to once-daily placebo, teriflunomide 7 mg, or teriflunomide 14 mg via an interactive voice recognition system. Treatment duration was variable, ending 48 weeks after the last patient was included. The primary endpoint was annualised relapse rate (number of relapses per patient-year) and the key secondary endpoint was time to sustained accumulation of disability (an EDSS score increase of at least 1 EDSS point sustained for a minimum of 12 weeks), both analysed in the modified intention-to-treat population (all patients who received at least one dose of assigned study medication). This study is registered with ClinicalTrials.gov, number NCT00751881. FINDINGS Between Sept 17, 2008, and Feb 17, 2011, 1169 patients were randomly assigned to a treatment group, of whom 388, 407, and 370 patients received at least one dose of placebo, teriflunomide 7 mg, or teriflunomide 14 mg, respectively. By the end of the study, the annualised relapse rate was higher in patients assigned to placebo (0.50 [95% CI 0.43-0.58]) than in those assigned to teriflunomide 14 mg (0.32 [0.27-0.38]; p=0.0001) or teriflunomide 7 mg (0.39 [0.33-0.46]; p=0.0183). Compared with placebo, teriflunomide 14 mg reduced the risk of sustained accumulation of disability (hazard ratio [HR] 0.68 [95% CI 0.47-1.00]; log-rank p=0.0442); however, teriflunomide 7 mg had no effect on sustained accumulation of disability (HR 0.95 [0.68-1.35]; log-rank p=0.7620). The most common adverse events were alanine aminotransferase increases (32 [8%] of 385 patients in the placebo group vs 46 [11%] of 409 patients in the teriflunomide 7 mg group vs 52 [14%] of 371 patients in the teriflunomide 14 mg group), hair thinning (17 [4%] vs 42 [10%] vs 50 [13%]), and headache (42 [11%] vs 60 [15%] vs 46 [12%]). Incidence of serious adverse events was similar in all treatment groups (47 [12%] vs 52 [13%] vs 44 [12%]). Four deaths occurred, none of which was considered to be related to study drug (respiratory infection in the placebo group, traffic accident in the teriflunomide 7 mg group, and suicide and septicaemia due to Gram-negative infection complicated by disseminated intravascular coagulopathy in the teriflunomide 14 mg group). INTERPRETATION Teriflunomide 14 mg was associated with a lower relapse rate and less disability accumulation compared with placebo, with a similar safety and tolerability profile to that reported in previous studies. These results confirm the dose effect reported in previous trials and support the use of teriflunomide 14 mg in patients with relapsing multiple sclerosis. FUNDING Genzyme, a Sanofi company.
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Affiliation(s)
| | | | | | - Mark S Freedman
- University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Aaron E Miller
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Jerry S Wolinsky
- University of Texas Health Science Center at Houston, Houston, TX, USA
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Vermersch P, Czlonkowska A, Grimaldi LME, Confavreux C, Comi G, Kappos L, Olsson TP, Benamor M, Bauer D, Truffinet P, Church M, Miller AE, Wolinsky JS, Freedman MS, O'Connor P. Teriflunomide versus subcutaneous interferon beta-1a in patients with relapsing multiple sclerosis: a randomised, controlled phase 3 trial. Mult Scler 2013; 20:705-16. [PMID: 24126064 DOI: 10.1177/1352458513507821] [Citation(s) in RCA: 233] [Impact Index Per Article: 21.2] [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: 12/18/2022]
Abstract
BACKGROUND In previous studies, teriflunomide significantly reduced the annualised relapse rate (ARR) and disability progression. OBJECTIVE This phase 3, rater-blinded study (NCT00883337) compared teriflunomide with interferon-beta-1a (IFNβ-1a). METHODS Patients with relapsing multiple sclerosis were randomised (1:1:1) to oral teriflunomide 7-or 14 mg, or subcutaneous IFNβ-1a 44 µg. The primary composite endpoint was time to failure, defined as first occurrence of confirmed relapse or permanent treatment discontinuation for any cause. Secondary endpoints included ARR, Fatigue Impact Scale (FIS) and Treatment Satisfaction Questionnaire for Medication (TSQM). The study was completed 48 weeks after the last patient was randomised. RESULTS Some 324 patients were randomised (IFNβ-1a: 104; teriflunomide 7 mg: 109; teriflunomide 14 mg: 111). No difference in time to failure was observed. There was no difference in ARR between teriflunomide 14 mg and IFNβ-1a, but ARR was significantly higher with teriflunomide 7 mg. FIS scores indicated more frequent fatigue with IFNβ-1a, though differences were only significant with teriflunomide 7 mg. TSQM scores were significantly higher with teriflunomide. There were no unexpected safety findings. CONCLUSION Effects on time to failure were comparable between teriflunomide and IFNβ-1a. There was no difference between teriflunomide 14 mg and IFNβ-1a on ARR, though ARR was higher with teriflunomide 7 mg. The teriflunomide safety profile was consistent with previous studies.
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Miller AE. Teriflunomide efficacy, safety and tolerability in patients with relapsing forms of multiple sclerosis. Neurodegener Dis Manag 2013. [DOI: 10.2217/nmt.13.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Teriflunomide is a once-daily, orally administered, disease-modifying therapy for the treatment of relapsing forms of multiple sclerosis. The clinical development program for teriflunomide is extensive, including four Phase III studies. Pivotal trials have demonstrated the effectiveness of teriflunomide 7- and 14-mg doses on relapse, disability progression and MRI activity, and long-term follow-up has revealed no new or unexpected safety signals. The multiple sclerosis treatment landscape is shifting; oral medications offer improved convenience and tolerability over disease-modifying therapy injections, and patients are being treated earlier in the disease course to prevent progression. Clinical knowledge to date indicates that teriflunomide is a viable treatment option to meet individual patient needs. Additional insight is expected in the postmarket setting.
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Affiliation(s)
- Aaron E Miller
- Icahn School of Medicine at Mount Sinai, Mount Sinai – The Corinne Goldsmith Dickinson Center for Multiple Sclerosis, 5 East 98th, Box 1138, New York, NY 10029, USA
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