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Expert: Don’t discourage pregnancy in MS patients; manage it
INDIANAPOLIS – If you feel overwhelmed by the notion of managing multiple sclerosis patients who seek your guidance in navigating their pregnancy, you’re not alone.
Comprehensive management programs for pregnant MS patients currently do not exist, even within most dedicated MS centers and clinics, Dr. Maria K. Houtchens said at the annual meeting of the Consortium of Multiple Sclerosis Centers.
“Individual providers have an interest in this area, but there are no guidelines for most physicians or nurse practitioners to follow yet,” she said. “The level of care these patients receive varies dramatically, from one part of the country to another and from one provider to the next.”
An estimated 50% of all pregnancies in the United States and about 40% of all pregnancies worldwide are unplanned.
“I believe that women with MS should receive support and counseling from their MS specialist on issues about possible pregnancy,” said Dr. Houtchens, a neurologist who directs the Women’s Health Program at the Partners MS Center at Brigham and Women’s Hospital, Boston. “I believe that we should all feel comfortable discussing with our patients the effects of pregnancy on their MS course and the reciprocal effect on pregnancy outcomes of their disease, the genetic risk of disease in their offspring, and optimal conception timing. We need to be able to talk to them freely about disease control before, during, and after pregnancy.”
Dr. Houtchens, one of the authors of a recent multinational systematic review on the topic noted that increasing numbers of MS patients with stable disease are choosing not to become pregnant (Obstet. Gynecol. 2014;124:1157-68). Others “want to get pregnant and feel cheated out of their life goal,” she said.
A large survey of female patients with MS from Canada found that more than three-quarters had not become pregnant since being diagnosed with the disease. The most common contributing factor across both MS-related and non–MS-related categories was completion of families prior to an MS diagnosis (53%). The top MS-related reasons that contributed to not having children were symptoms interfering with parenting, burdening the partner, and finances (Mult. Scler. 2013;19:351-8).
“It’s only in the last 2-3 decades that this issue has come to the forefront in caring for MS patients,” she said. “Previous to that, a lot of colleagues would discourage patients from becoming pregnant. Some of those attitudes persist to this day. There’s a perception of disapproval from health care providers on the part of the patient, and from their family and peers, and historic misconceptions. Our goal as physicians is to help women live lives to their fullest potential with a disease that can’t be cured. We should not discourage our patients from becoming pregnant.”
To optimize chances of conception, she recommended that oral contraceptives be stopped 2-3 months prior to conception attempts, and patients should be advised to transition to mechanical birth control. The optimal “fertility window” is a 6-day period, ending with the ovulation day. This window can be estimated based on duration of menstrual cycle, cervical mucus, and basal body temperature, as well as commercially available ovulation kits. Intercourse is most likely going to result in a pregnancy if attempted within a 3-day period, ending with the ovulation day. Moderate alcohol consumption, smoking, drug use, and vaginal lubricant use decrease the chance of contraception, she said.
Assisted reproductive technologies, if associated with failed pregnancy attempts, can lead to an increased relapse rate.
“If somebody really wants to have a child and are not able to conceive on their own, they may certainly consider ART; it’s all about education,” Dr. Houtchens said. “You just need to tell them what to expect and that they might have a higher risk of relapses if their attempt is unsuccessful.”
According to the medical literature, an MS patient’s prepregnancy annualized relapse rate predicts her risk for relapse during the postpartum period. “From that perspective, if you have the luxury of time, you ideally try to make sure that her disease is stabilized for the year before she becomes pregnant,” she said. “That means if she has an active MRI or has had a couple of attacks on whatever drug she’s taking, you talk to her about that, and you change the medication and repeat the MRI after the medication is changed to try to make sure that her disease is stable before she becomes pregnant. Hopefully that will help prevent postpartum attacks.”
Dr. Houtchens recommends standard preconception care including prenatal vitamins with 0.4 mg-1 mg of daily folate, smoking and alcohol cessation, improved sleep hygiene, and vitamin D3 supplementation. Low levels of vitamin D3 are associated with adverse pregnancy outcomes, and a poorer clinical and radiologic MS course. Low levels may also be associated with increased MS risk in offspring.
“A pregnancy test should be administered prior to every treatment with a chemotherapeutic or cytotoxic agent in a woman of child-bearing age, even if she thinks her periods have ceased as a result of chemotherapy treatment,” she said. “They may have ceased due to pregnancy, and we don’t want to treat our pregnant patients with chemotherapy.”
The approximate risk of MS is 1 in 500 in the general population, 1 in 100 in people with an affected second-degree relative, 1 in 50 with an affected first-degree relative, and 1 in 4 in monozygotic twins born to an affected mother, according to Dr. Houtchens.
Babies born to MS moms face a risk of being slightly smaller for gestational age by weight (odds ratio, 1.45) but their Apgar scores are the same as their healthy mom counterpart babies. MS moms face a slight risk for operative deliveries but no increased risk for birth defects or other adverse fetal outcomes specifically related to MS. The method of labor and delivery does not impact the postpartum course of the disease, she said.
“Epidural anesthesia is perfectly safe and does not impact the postpartum course of MS,” Dr. Houtchens said. “There’s still an ongoing misconception [about this], especially among obstetric providers and anesthesiologists. Multiple studies have been published stating that there is no increased risk of relapse in these patients after they get an epidural. If they don’t want an epidural, that’s okay, but they shouldn’t be denied it because they have MS.”
Secondary MS symptoms may be affected by pregnancy, including fatigue, bladder symptoms, and mobility difficulty due to increased weight. IV corticosteroids are used widely to treat MS relapses during pregnancy, as well as in obstetrics to speed fetal lung maturity.
Steroids “cross the placental barrier and may increase the risk of cleft palate when used in the first trimester or may cause lower birth weight in the baby and earlier than expected delivery. They could also in theory delay healing for the mother after giving birth,” she said.
However, prednisone, prednisolone, and methylprednisolone can be administered with low levels of fetal exposure. “These agents are metabolized to inactive forms by 11 beta-hydroxysteroid dehydrogenase in the placenta, allowing less than 10% of the maternal dose to reach the fetus,” she said. Betamethasone and dexamethasone cross the placenta with minimal metabolism, leading to direct full-dose effects on the fetus.
Dr. Houtchens cautioned that none of the available MS drugs should be used in pregnant patients.
“It appears that pregnancy itself is protective enough that we don’t need to use a drug to keep them healthier,” she said.
For a nonlactating patient, it’s safe to resume MS therapy within 1 week after birth. For a lactating patient with previously active disease, it may be safe to administer monthly steroids or monthly IVIG, instructing them to discontinue breastfeeding for 24 hours after treatment. In breast milk, beta-interferon agents are found at 0.006% of the maternal dose. Oral small molecules such as fingolimod and dimethyl fumarate “are freely passed in breast milk at a lower level than in sera but are more likely to directly affect the infant’s immune/neurological systems,” Dr. Houtchens said. “Hepatic clearance is slower in infants. We don’t have anyone at our MS center taking any MS medications and breastfeeding. Is this the right thing to do? I don’t know. But if you have someone who really wants to breastfeed, you could theoretically put them on an injectable medication.”
MRI should be repeated within 6 months postpartum to assess radiographic disease activity, she recommended.
Dr. Houtchers pointed out that postpartum depression is common in mothers with MS, “and it’s probably under-studied in general.” In fact, the lifetime prevalence of major depressive disorder in people with MS is estimated to be approximately 50%, while the rate of suicides among people with MS is 7.5 times greater than that of the general population.
Helping MS patients navigate conception, pregnancy, and the postpartum period is just the beginning.
“You’re still going to be her doctor,” Dr. Houtchens said. “She’s still going to have that child for the rest of her life. How is she going to deal with raising the child with all of the symptoms of her disease over time? How is she going to relate to her child? You’re going to walk this road with your patients, as one of their most important health care providers.”
Dr. Houtchens disclosed that she has received research grants from Genzyme Sanofi, Biogen Idec, and Novartis. She has also served as a consultant for Teva Pharmaceuticals, Genzyme Sanofi, Questcor, Biogen Idec, and Novartis.
On Twitter @dougbrunk
INDIANAPOLIS – If you feel overwhelmed by the notion of managing multiple sclerosis patients who seek your guidance in navigating their pregnancy, you’re not alone.
Comprehensive management programs for pregnant MS patients currently do not exist, even within most dedicated MS centers and clinics, Dr. Maria K. Houtchens said at the annual meeting of the Consortium of Multiple Sclerosis Centers.
“Individual providers have an interest in this area, but there are no guidelines for most physicians or nurse practitioners to follow yet,” she said. “The level of care these patients receive varies dramatically, from one part of the country to another and from one provider to the next.”
An estimated 50% of all pregnancies in the United States and about 40% of all pregnancies worldwide are unplanned.
“I believe that women with MS should receive support and counseling from their MS specialist on issues about possible pregnancy,” said Dr. Houtchens, a neurologist who directs the Women’s Health Program at the Partners MS Center at Brigham and Women’s Hospital, Boston. “I believe that we should all feel comfortable discussing with our patients the effects of pregnancy on their MS course and the reciprocal effect on pregnancy outcomes of their disease, the genetic risk of disease in their offspring, and optimal conception timing. We need to be able to talk to them freely about disease control before, during, and after pregnancy.”
Dr. Houtchens, one of the authors of a recent multinational systematic review on the topic noted that increasing numbers of MS patients with stable disease are choosing not to become pregnant (Obstet. Gynecol. 2014;124:1157-68). Others “want to get pregnant and feel cheated out of their life goal,” she said.
A large survey of female patients with MS from Canada found that more than three-quarters had not become pregnant since being diagnosed with the disease. The most common contributing factor across both MS-related and non–MS-related categories was completion of families prior to an MS diagnosis (53%). The top MS-related reasons that contributed to not having children were symptoms interfering with parenting, burdening the partner, and finances (Mult. Scler. 2013;19:351-8).
“It’s only in the last 2-3 decades that this issue has come to the forefront in caring for MS patients,” she said. “Previous to that, a lot of colleagues would discourage patients from becoming pregnant. Some of those attitudes persist to this day. There’s a perception of disapproval from health care providers on the part of the patient, and from their family and peers, and historic misconceptions. Our goal as physicians is to help women live lives to their fullest potential with a disease that can’t be cured. We should not discourage our patients from becoming pregnant.”
To optimize chances of conception, she recommended that oral contraceptives be stopped 2-3 months prior to conception attempts, and patients should be advised to transition to mechanical birth control. The optimal “fertility window” is a 6-day period, ending with the ovulation day. This window can be estimated based on duration of menstrual cycle, cervical mucus, and basal body temperature, as well as commercially available ovulation kits. Intercourse is most likely going to result in a pregnancy if attempted within a 3-day period, ending with the ovulation day. Moderate alcohol consumption, smoking, drug use, and vaginal lubricant use decrease the chance of contraception, she said.
Assisted reproductive technologies, if associated with failed pregnancy attempts, can lead to an increased relapse rate.
“If somebody really wants to have a child and are not able to conceive on their own, they may certainly consider ART; it’s all about education,” Dr. Houtchens said. “You just need to tell them what to expect and that they might have a higher risk of relapses if their attempt is unsuccessful.”
According to the medical literature, an MS patient’s prepregnancy annualized relapse rate predicts her risk for relapse during the postpartum period. “From that perspective, if you have the luxury of time, you ideally try to make sure that her disease is stabilized for the year before she becomes pregnant,” she said. “That means if she has an active MRI or has had a couple of attacks on whatever drug she’s taking, you talk to her about that, and you change the medication and repeat the MRI after the medication is changed to try to make sure that her disease is stable before she becomes pregnant. Hopefully that will help prevent postpartum attacks.”
Dr. Houtchens recommends standard preconception care including prenatal vitamins with 0.4 mg-1 mg of daily folate, smoking and alcohol cessation, improved sleep hygiene, and vitamin D3 supplementation. Low levels of vitamin D3 are associated with adverse pregnancy outcomes, and a poorer clinical and radiologic MS course. Low levels may also be associated with increased MS risk in offspring.
“A pregnancy test should be administered prior to every treatment with a chemotherapeutic or cytotoxic agent in a woman of child-bearing age, even if she thinks her periods have ceased as a result of chemotherapy treatment,” she said. “They may have ceased due to pregnancy, and we don’t want to treat our pregnant patients with chemotherapy.”
The approximate risk of MS is 1 in 500 in the general population, 1 in 100 in people with an affected second-degree relative, 1 in 50 with an affected first-degree relative, and 1 in 4 in monozygotic twins born to an affected mother, according to Dr. Houtchens.
Babies born to MS moms face a risk of being slightly smaller for gestational age by weight (odds ratio, 1.45) but their Apgar scores are the same as their healthy mom counterpart babies. MS moms face a slight risk for operative deliveries but no increased risk for birth defects or other adverse fetal outcomes specifically related to MS. The method of labor and delivery does not impact the postpartum course of the disease, she said.
“Epidural anesthesia is perfectly safe and does not impact the postpartum course of MS,” Dr. Houtchens said. “There’s still an ongoing misconception [about this], especially among obstetric providers and anesthesiologists. Multiple studies have been published stating that there is no increased risk of relapse in these patients after they get an epidural. If they don’t want an epidural, that’s okay, but they shouldn’t be denied it because they have MS.”
Secondary MS symptoms may be affected by pregnancy, including fatigue, bladder symptoms, and mobility difficulty due to increased weight. IV corticosteroids are used widely to treat MS relapses during pregnancy, as well as in obstetrics to speed fetal lung maturity.
Steroids “cross the placental barrier and may increase the risk of cleft palate when used in the first trimester or may cause lower birth weight in the baby and earlier than expected delivery. They could also in theory delay healing for the mother after giving birth,” she said.
However, prednisone, prednisolone, and methylprednisolone can be administered with low levels of fetal exposure. “These agents are metabolized to inactive forms by 11 beta-hydroxysteroid dehydrogenase in the placenta, allowing less than 10% of the maternal dose to reach the fetus,” she said. Betamethasone and dexamethasone cross the placenta with minimal metabolism, leading to direct full-dose effects on the fetus.
Dr. Houtchens cautioned that none of the available MS drugs should be used in pregnant patients.
“It appears that pregnancy itself is protective enough that we don’t need to use a drug to keep them healthier,” she said.
For a nonlactating patient, it’s safe to resume MS therapy within 1 week after birth. For a lactating patient with previously active disease, it may be safe to administer monthly steroids or monthly IVIG, instructing them to discontinue breastfeeding for 24 hours after treatment. In breast milk, beta-interferon agents are found at 0.006% of the maternal dose. Oral small molecules such as fingolimod and dimethyl fumarate “are freely passed in breast milk at a lower level than in sera but are more likely to directly affect the infant’s immune/neurological systems,” Dr. Houtchens said. “Hepatic clearance is slower in infants. We don’t have anyone at our MS center taking any MS medications and breastfeeding. Is this the right thing to do? I don’t know. But if you have someone who really wants to breastfeed, you could theoretically put them on an injectable medication.”
MRI should be repeated within 6 months postpartum to assess radiographic disease activity, she recommended.
Dr. Houtchers pointed out that postpartum depression is common in mothers with MS, “and it’s probably under-studied in general.” In fact, the lifetime prevalence of major depressive disorder in people with MS is estimated to be approximately 50%, while the rate of suicides among people with MS is 7.5 times greater than that of the general population.
Helping MS patients navigate conception, pregnancy, and the postpartum period is just the beginning.
“You’re still going to be her doctor,” Dr. Houtchens said. “She’s still going to have that child for the rest of her life. How is she going to deal with raising the child with all of the symptoms of her disease over time? How is she going to relate to her child? You’re going to walk this road with your patients, as one of their most important health care providers.”
Dr. Houtchens disclosed that she has received research grants from Genzyme Sanofi, Biogen Idec, and Novartis. She has also served as a consultant for Teva Pharmaceuticals, Genzyme Sanofi, Questcor, Biogen Idec, and Novartis.
On Twitter @dougbrunk
INDIANAPOLIS – If you feel overwhelmed by the notion of managing multiple sclerosis patients who seek your guidance in navigating their pregnancy, you’re not alone.
Comprehensive management programs for pregnant MS patients currently do not exist, even within most dedicated MS centers and clinics, Dr. Maria K. Houtchens said at the annual meeting of the Consortium of Multiple Sclerosis Centers.
“Individual providers have an interest in this area, but there are no guidelines for most physicians or nurse practitioners to follow yet,” she said. “The level of care these patients receive varies dramatically, from one part of the country to another and from one provider to the next.”
An estimated 50% of all pregnancies in the United States and about 40% of all pregnancies worldwide are unplanned.
“I believe that women with MS should receive support and counseling from their MS specialist on issues about possible pregnancy,” said Dr. Houtchens, a neurologist who directs the Women’s Health Program at the Partners MS Center at Brigham and Women’s Hospital, Boston. “I believe that we should all feel comfortable discussing with our patients the effects of pregnancy on their MS course and the reciprocal effect on pregnancy outcomes of their disease, the genetic risk of disease in their offspring, and optimal conception timing. We need to be able to talk to them freely about disease control before, during, and after pregnancy.”
Dr. Houtchens, one of the authors of a recent multinational systematic review on the topic noted that increasing numbers of MS patients with stable disease are choosing not to become pregnant (Obstet. Gynecol. 2014;124:1157-68). Others “want to get pregnant and feel cheated out of their life goal,” she said.
A large survey of female patients with MS from Canada found that more than three-quarters had not become pregnant since being diagnosed with the disease. The most common contributing factor across both MS-related and non–MS-related categories was completion of families prior to an MS diagnosis (53%). The top MS-related reasons that contributed to not having children were symptoms interfering with parenting, burdening the partner, and finances (Mult. Scler. 2013;19:351-8).
“It’s only in the last 2-3 decades that this issue has come to the forefront in caring for MS patients,” she said. “Previous to that, a lot of colleagues would discourage patients from becoming pregnant. Some of those attitudes persist to this day. There’s a perception of disapproval from health care providers on the part of the patient, and from their family and peers, and historic misconceptions. Our goal as physicians is to help women live lives to their fullest potential with a disease that can’t be cured. We should not discourage our patients from becoming pregnant.”
To optimize chances of conception, she recommended that oral contraceptives be stopped 2-3 months prior to conception attempts, and patients should be advised to transition to mechanical birth control. The optimal “fertility window” is a 6-day period, ending with the ovulation day. This window can be estimated based on duration of menstrual cycle, cervical mucus, and basal body temperature, as well as commercially available ovulation kits. Intercourse is most likely going to result in a pregnancy if attempted within a 3-day period, ending with the ovulation day. Moderate alcohol consumption, smoking, drug use, and vaginal lubricant use decrease the chance of contraception, she said.
Assisted reproductive technologies, if associated with failed pregnancy attempts, can lead to an increased relapse rate.
“If somebody really wants to have a child and are not able to conceive on their own, they may certainly consider ART; it’s all about education,” Dr. Houtchens said. “You just need to tell them what to expect and that they might have a higher risk of relapses if their attempt is unsuccessful.”
According to the medical literature, an MS patient’s prepregnancy annualized relapse rate predicts her risk for relapse during the postpartum period. “From that perspective, if you have the luxury of time, you ideally try to make sure that her disease is stabilized for the year before she becomes pregnant,” she said. “That means if she has an active MRI or has had a couple of attacks on whatever drug she’s taking, you talk to her about that, and you change the medication and repeat the MRI after the medication is changed to try to make sure that her disease is stable before she becomes pregnant. Hopefully that will help prevent postpartum attacks.”
Dr. Houtchens recommends standard preconception care including prenatal vitamins with 0.4 mg-1 mg of daily folate, smoking and alcohol cessation, improved sleep hygiene, and vitamin D3 supplementation. Low levels of vitamin D3 are associated with adverse pregnancy outcomes, and a poorer clinical and radiologic MS course. Low levels may also be associated with increased MS risk in offspring.
“A pregnancy test should be administered prior to every treatment with a chemotherapeutic or cytotoxic agent in a woman of child-bearing age, even if she thinks her periods have ceased as a result of chemotherapy treatment,” she said. “They may have ceased due to pregnancy, and we don’t want to treat our pregnant patients with chemotherapy.”
The approximate risk of MS is 1 in 500 in the general population, 1 in 100 in people with an affected second-degree relative, 1 in 50 with an affected first-degree relative, and 1 in 4 in monozygotic twins born to an affected mother, according to Dr. Houtchens.
Babies born to MS moms face a risk of being slightly smaller for gestational age by weight (odds ratio, 1.45) but their Apgar scores are the same as their healthy mom counterpart babies. MS moms face a slight risk for operative deliveries but no increased risk for birth defects or other adverse fetal outcomes specifically related to MS. The method of labor and delivery does not impact the postpartum course of the disease, she said.
“Epidural anesthesia is perfectly safe and does not impact the postpartum course of MS,” Dr. Houtchens said. “There’s still an ongoing misconception [about this], especially among obstetric providers and anesthesiologists. Multiple studies have been published stating that there is no increased risk of relapse in these patients after they get an epidural. If they don’t want an epidural, that’s okay, but they shouldn’t be denied it because they have MS.”
Secondary MS symptoms may be affected by pregnancy, including fatigue, bladder symptoms, and mobility difficulty due to increased weight. IV corticosteroids are used widely to treat MS relapses during pregnancy, as well as in obstetrics to speed fetal lung maturity.
Steroids “cross the placental barrier and may increase the risk of cleft palate when used in the first trimester or may cause lower birth weight in the baby and earlier than expected delivery. They could also in theory delay healing for the mother after giving birth,” she said.
However, prednisone, prednisolone, and methylprednisolone can be administered with low levels of fetal exposure. “These agents are metabolized to inactive forms by 11 beta-hydroxysteroid dehydrogenase in the placenta, allowing less than 10% of the maternal dose to reach the fetus,” she said. Betamethasone and dexamethasone cross the placenta with minimal metabolism, leading to direct full-dose effects on the fetus.
Dr. Houtchens cautioned that none of the available MS drugs should be used in pregnant patients.
“It appears that pregnancy itself is protective enough that we don’t need to use a drug to keep them healthier,” she said.
For a nonlactating patient, it’s safe to resume MS therapy within 1 week after birth. For a lactating patient with previously active disease, it may be safe to administer monthly steroids or monthly IVIG, instructing them to discontinue breastfeeding for 24 hours after treatment. In breast milk, beta-interferon agents are found at 0.006% of the maternal dose. Oral small molecules such as fingolimod and dimethyl fumarate “are freely passed in breast milk at a lower level than in sera but are more likely to directly affect the infant’s immune/neurological systems,” Dr. Houtchens said. “Hepatic clearance is slower in infants. We don’t have anyone at our MS center taking any MS medications and breastfeeding. Is this the right thing to do? I don’t know. But if you have someone who really wants to breastfeed, you could theoretically put them on an injectable medication.”
MRI should be repeated within 6 months postpartum to assess radiographic disease activity, she recommended.
Dr. Houtchers pointed out that postpartum depression is common in mothers with MS, “and it’s probably under-studied in general.” In fact, the lifetime prevalence of major depressive disorder in people with MS is estimated to be approximately 50%, while the rate of suicides among people with MS is 7.5 times greater than that of the general population.
Helping MS patients navigate conception, pregnancy, and the postpartum period is just the beginning.
“You’re still going to be her doctor,” Dr. Houtchens said. “She’s still going to have that child for the rest of her life. How is she going to deal with raising the child with all of the symptoms of her disease over time? How is she going to relate to her child? You’re going to walk this road with your patients, as one of their most important health care providers.”
Dr. Houtchens disclosed that she has received research grants from Genzyme Sanofi, Biogen Idec, and Novartis. She has also served as a consultant for Teva Pharmaceuticals, Genzyme Sanofi, Questcor, Biogen Idec, and Novartis.
On Twitter @dougbrunk
EXPERT ANALYSIS AT THE CMSC ANNUAL MEETING
Daclizumab HYP May Improve Ambulation and Cognition, Compared With Interferon β-1a
INDIANAPOLIS—Compared with interferon β-1a, daclizumab high-yield process (DAC HYP) may provide greater improvement in the patient-centered outcomes of ambulation and cognition for patients with relapsing-remitting multiple sclerosis (MS), according to data presented at the 2015 CMSC Annual Meeting.
The results come from a post hoc analysis of results from the DECIDE study. In that randomized, double-blind trial, Michael Kaufman, MD, a neurologist at Cole Neuroscience Center in Knoxville, Tennessee, and colleagues found that DAC HYP reduced clinical and radiographic disease activity in patients with relapsing-remitting MS, compared with interferon β-1a. The researchers incorporated changes in the MS Functional Composite (MSFC) and the Symbol Digit Modalities Test (SDMT) over 96 weeks as tertiary end points in the DECIDE trial to compare the effects of the two therapies on ambulation, hand and arm dexterity, and cognition.
Eligible participants were between ages 18 and 55 and had an Expanded Disability Status Scale (EDSS) score between 0 and 5. Patients were randomized to 150 mg of DAC HYP subcutaneously every four weeks or 30 mg of interferon β-1a once weekly. The study lasted for 144 weeks.
In all, 919 patients received DAC HYP, and 922 participants received interferon β-1a. Mean baseline EDSS was 2.48 for the DAC HYP group and 2.54 for the interferon β-1a group. Over 96 weeks, the median improvement from baseline in MSFC z score was 0.091 for patients receiving DAC HYP, compared with 0.055 for patients receiving interferon β-1a.
The most significant median z score change in an individual component of the MSFC was in the Nine-Hole Peg Test. This change was 0.063 for patients receiving DAC HYP and 0.017 for patients receiving interferon β-1a. Median z score change for the Timed 25-Foot Walk was 0.000 for the DAC HYP group and –0.017 for the interferon β-1a group. Median z score change for the Paced Auditory Serial Addition Test-3 was not different between groups at Week 96, but patients receiving DAC HYP showed earlier improvements in this measure. Mean change in SDMT from baseline over 96 weeks was 4.08 for the DAC HYP group, compared with 2.89 for the interferon β-1a group.
The data suggest that DAC HYP has beneficial effects for cognitive function, “which is extremely important to MS patients,” said Dr. Kaufman. The study “supports the idea that daclizumab may in the future have a place in the therapeutic armamentarium of MS,” he concluded.
—Erik Greb
INDIANAPOLIS—Compared with interferon β-1a, daclizumab high-yield process (DAC HYP) may provide greater improvement in the patient-centered outcomes of ambulation and cognition for patients with relapsing-remitting multiple sclerosis (MS), according to data presented at the 2015 CMSC Annual Meeting.
The results come from a post hoc analysis of results from the DECIDE study. In that randomized, double-blind trial, Michael Kaufman, MD, a neurologist at Cole Neuroscience Center in Knoxville, Tennessee, and colleagues found that DAC HYP reduced clinical and radiographic disease activity in patients with relapsing-remitting MS, compared with interferon β-1a. The researchers incorporated changes in the MS Functional Composite (MSFC) and the Symbol Digit Modalities Test (SDMT) over 96 weeks as tertiary end points in the DECIDE trial to compare the effects of the two therapies on ambulation, hand and arm dexterity, and cognition.
Eligible participants were between ages 18 and 55 and had an Expanded Disability Status Scale (EDSS) score between 0 and 5. Patients were randomized to 150 mg of DAC HYP subcutaneously every four weeks or 30 mg of interferon β-1a once weekly. The study lasted for 144 weeks.
In all, 919 patients received DAC HYP, and 922 participants received interferon β-1a. Mean baseline EDSS was 2.48 for the DAC HYP group and 2.54 for the interferon β-1a group. Over 96 weeks, the median improvement from baseline in MSFC z score was 0.091 for patients receiving DAC HYP, compared with 0.055 for patients receiving interferon β-1a.
The most significant median z score change in an individual component of the MSFC was in the Nine-Hole Peg Test. This change was 0.063 for patients receiving DAC HYP and 0.017 for patients receiving interferon β-1a. Median z score change for the Timed 25-Foot Walk was 0.000 for the DAC HYP group and –0.017 for the interferon β-1a group. Median z score change for the Paced Auditory Serial Addition Test-3 was not different between groups at Week 96, but patients receiving DAC HYP showed earlier improvements in this measure. Mean change in SDMT from baseline over 96 weeks was 4.08 for the DAC HYP group, compared with 2.89 for the interferon β-1a group.
The data suggest that DAC HYP has beneficial effects for cognitive function, “which is extremely important to MS patients,” said Dr. Kaufman. The study “supports the idea that daclizumab may in the future have a place in the therapeutic armamentarium of MS,” he concluded.
—Erik Greb
INDIANAPOLIS—Compared with interferon β-1a, daclizumab high-yield process (DAC HYP) may provide greater improvement in the patient-centered outcomes of ambulation and cognition for patients with relapsing-remitting multiple sclerosis (MS), according to data presented at the 2015 CMSC Annual Meeting.
The results come from a post hoc analysis of results from the DECIDE study. In that randomized, double-blind trial, Michael Kaufman, MD, a neurologist at Cole Neuroscience Center in Knoxville, Tennessee, and colleagues found that DAC HYP reduced clinical and radiographic disease activity in patients with relapsing-remitting MS, compared with interferon β-1a. The researchers incorporated changes in the MS Functional Composite (MSFC) and the Symbol Digit Modalities Test (SDMT) over 96 weeks as tertiary end points in the DECIDE trial to compare the effects of the two therapies on ambulation, hand and arm dexterity, and cognition.
Eligible participants were between ages 18 and 55 and had an Expanded Disability Status Scale (EDSS) score between 0 and 5. Patients were randomized to 150 mg of DAC HYP subcutaneously every four weeks or 30 mg of interferon β-1a once weekly. The study lasted for 144 weeks.
In all, 919 patients received DAC HYP, and 922 participants received interferon β-1a. Mean baseline EDSS was 2.48 for the DAC HYP group and 2.54 for the interferon β-1a group. Over 96 weeks, the median improvement from baseline in MSFC z score was 0.091 for patients receiving DAC HYP, compared with 0.055 for patients receiving interferon β-1a.
The most significant median z score change in an individual component of the MSFC was in the Nine-Hole Peg Test. This change was 0.063 for patients receiving DAC HYP and 0.017 for patients receiving interferon β-1a. Median z score change for the Timed 25-Foot Walk was 0.000 for the DAC HYP group and –0.017 for the interferon β-1a group. Median z score change for the Paced Auditory Serial Addition Test-3 was not different between groups at Week 96, but patients receiving DAC HYP showed earlier improvements in this measure. Mean change in SDMT from baseline over 96 weeks was 4.08 for the DAC HYP group, compared with 2.89 for the interferon β-1a group.
The data suggest that DAC HYP has beneficial effects for cognitive function, “which is extremely important to MS patients,” said Dr. Kaufman. The study “supports the idea that daclizumab may in the future have a place in the therapeutic armamentarium of MS,” he concluded.
—Erik Greb
Alemtuzumab May Suppress Disease Activity for Four Years
INDIANAPOLIS—Most patients with relapsing-remitting multiple sclerosis (MS) remain free of new MRI activity for four years after initiating treatment with alemtuzumab, according to data presented at the 2015 CMSC Annual Meeting. Alemtuzumab also appears to slow the rate of brain volume loss, compared with interferon beta. The drug’s durable effects may result from the distinct pattern of lymphocyte depletion and repopulation that follows treatment, said Anthony Traboulsee, MD, Associate Professor of Neurology at the University of British Columbia in Vancouver.
The data result from four-year follow-up of participants in the CARE-MS II trial. In that study, patients with relapsing-remitting MS who had had an inadequate response to prior therapy (defined as at least one relapse) were randomized to alemtuzumab or subcutaneous interferon beta-1a. After two years, patients receiving alemtuzumab had a 49% decrease in annualized relapse rate and a 42% decrease in six-month sustained accumulation of disability, compared with patients who received interferon beta-1a. In addition, more patients in the alemtuzumab group were free of MRI activity, compared with the interferon group.
The open-label extension study was designed to observe the effect of alemtuzumab on MRI outcomes over four years. In this study, patients randomized to interferon had the option of receiving alemtuzumab, and patients randomized to alemtuzumab were allowed to receive additional treatment if they had breakthrough clinical or MRI activity.
About 93% of the original alemtuzumab group entered the extension study. Approximately 68% of these participants were clinically and radiologically stable and did not require further treatments during the two years of the extension. The proportion of participants receiving alemtuzumab who were free of MRI activity was 68.4% in Year 3 and 69.9% in Year 4. This proportion remained stable, compared with that of the original study. The proportion of patients receiving alemtuzumab with no evidence of disease activity (ie, clinical or MRI activity) was 52.9% at Year 3 and 54.5% at Year 4.
The median yearly loss in brain volume was smaller in Years 3 and 4 than during the original study for patients receiving alemtuzumab. Median yearly brain volume change was –0.22% at Year 2, –0.10% at Year 3, and –0.19% at Year 4. “These results reflect a reduction in focal inflammation with alemtuzumab treatment,” said Dr. Traboulsee. “Together, these findings indicate that alemtuzumab represents a novel and durable treatment approach for relapsing-remitting MS.”
—Erik Greb
INDIANAPOLIS—Most patients with relapsing-remitting multiple sclerosis (MS) remain free of new MRI activity for four years after initiating treatment with alemtuzumab, according to data presented at the 2015 CMSC Annual Meeting. Alemtuzumab also appears to slow the rate of brain volume loss, compared with interferon beta. The drug’s durable effects may result from the distinct pattern of lymphocyte depletion and repopulation that follows treatment, said Anthony Traboulsee, MD, Associate Professor of Neurology at the University of British Columbia in Vancouver.
The data result from four-year follow-up of participants in the CARE-MS II trial. In that study, patients with relapsing-remitting MS who had had an inadequate response to prior therapy (defined as at least one relapse) were randomized to alemtuzumab or subcutaneous interferon beta-1a. After two years, patients receiving alemtuzumab had a 49% decrease in annualized relapse rate and a 42% decrease in six-month sustained accumulation of disability, compared with patients who received interferon beta-1a. In addition, more patients in the alemtuzumab group were free of MRI activity, compared with the interferon group.
The open-label extension study was designed to observe the effect of alemtuzumab on MRI outcomes over four years. In this study, patients randomized to interferon had the option of receiving alemtuzumab, and patients randomized to alemtuzumab were allowed to receive additional treatment if they had breakthrough clinical or MRI activity.
About 93% of the original alemtuzumab group entered the extension study. Approximately 68% of these participants were clinically and radiologically stable and did not require further treatments during the two years of the extension. The proportion of participants receiving alemtuzumab who were free of MRI activity was 68.4% in Year 3 and 69.9% in Year 4. This proportion remained stable, compared with that of the original study. The proportion of patients receiving alemtuzumab with no evidence of disease activity (ie, clinical or MRI activity) was 52.9% at Year 3 and 54.5% at Year 4.
The median yearly loss in brain volume was smaller in Years 3 and 4 than during the original study for patients receiving alemtuzumab. Median yearly brain volume change was –0.22% at Year 2, –0.10% at Year 3, and –0.19% at Year 4. “These results reflect a reduction in focal inflammation with alemtuzumab treatment,” said Dr. Traboulsee. “Together, these findings indicate that alemtuzumab represents a novel and durable treatment approach for relapsing-remitting MS.”
—Erik Greb
INDIANAPOLIS—Most patients with relapsing-remitting multiple sclerosis (MS) remain free of new MRI activity for four years after initiating treatment with alemtuzumab, according to data presented at the 2015 CMSC Annual Meeting. Alemtuzumab also appears to slow the rate of brain volume loss, compared with interferon beta. The drug’s durable effects may result from the distinct pattern of lymphocyte depletion and repopulation that follows treatment, said Anthony Traboulsee, MD, Associate Professor of Neurology at the University of British Columbia in Vancouver.
The data result from four-year follow-up of participants in the CARE-MS II trial. In that study, patients with relapsing-remitting MS who had had an inadequate response to prior therapy (defined as at least one relapse) were randomized to alemtuzumab or subcutaneous interferon beta-1a. After two years, patients receiving alemtuzumab had a 49% decrease in annualized relapse rate and a 42% decrease in six-month sustained accumulation of disability, compared with patients who received interferon beta-1a. In addition, more patients in the alemtuzumab group were free of MRI activity, compared with the interferon group.
The open-label extension study was designed to observe the effect of alemtuzumab on MRI outcomes over four years. In this study, patients randomized to interferon had the option of receiving alemtuzumab, and patients randomized to alemtuzumab were allowed to receive additional treatment if they had breakthrough clinical or MRI activity.
About 93% of the original alemtuzumab group entered the extension study. Approximately 68% of these participants were clinically and radiologically stable and did not require further treatments during the two years of the extension. The proportion of participants receiving alemtuzumab who were free of MRI activity was 68.4% in Year 3 and 69.9% in Year 4. This proportion remained stable, compared with that of the original study. The proportion of patients receiving alemtuzumab with no evidence of disease activity (ie, clinical or MRI activity) was 52.9% at Year 3 and 54.5% at Year 4.
The median yearly loss in brain volume was smaller in Years 3 and 4 than during the original study for patients receiving alemtuzumab. Median yearly brain volume change was –0.22% at Year 2, –0.10% at Year 3, and –0.19% at Year 4. “These results reflect a reduction in focal inflammation with alemtuzumab treatment,” said Dr. Traboulsee. “Together, these findings indicate that alemtuzumab represents a novel and durable treatment approach for relapsing-remitting MS.”
—Erik Greb
Switching From Natalizumab to Dimethyl Fumarate: Real-World Experience
INDIANAPOLIS—A majority of patients remain stable when switching from natalizumab to dimethyl fumarate, according to data presented at the 2015 CMSC Annual Meeting. Factors such as sex, age, and duration of natalizumab treatment may predict the probability of a successful transition, reported lead author Faria S. Amjad, MD, of Georgetown University Hospital in Washington, DC, and research colleagues.
Natalizumab is a monoclonal antibody that prevents entry of leukocytes into the CNS. This mechanism of action has made it one of the most effective therapies against multiple sclerosis (MS). However, natalizumab’s use is limited by its risk of progressive multifocal leukoencephalopathy (PML). Moreover, switching from natalizumab to another therapeutic agent is made even more complex, as there is an increased risk of rebound inflammation. Dimethyl fumarate is an oral agent that offers a therapeutic alternative to patients stopping natalizumab. However, the safety and efficacy of this switch have not been studied.
To assess the stability of patients switched from natalizumab to dimethyl fumarate, Dr. Amjad and colleagues conducted a telephone survey and chart review for 66 patients with relapsing-remitting MS who had been switched from natalizumab to dimethyl fumarate. Factors analyzed included age, gender, duration on natalizumab, and duration on dimethyl fumarate.
A total of 66 patients were surveyed; 47 (71.22%) remained stable when switched to dimethyl fumarate, and 19 (28.78%) were found to be unstable on dimethyl fumarate. While the findings were not statistically significant, several trends were noted. Female patients were 2.9 times more likely to be unstable, compared with males. Patients younger than 60 were 1.8 times more likely to be unstable, compared with patients older than 60. Patients on natalizumab for less than two years were 2.4 times more likely to be unstable, compared with patients on natulizumab for more than two years. Patients who have an eight-week or less gap between natulizumab and dimethyl fumarate are just as likely to develop instability as patients with more than an eight-week gap between treatments. Patients who are on dimethyl fumarate for less than six months are 0.6 times less likely to be unstable than patients on dimethyl fumarate for longer than six months. In other words, patients on dimethyl fumarate for longer than six months are 1.7 times more likely to be unstable.
According to the researchers, an extension of this study will look at MRI changes and relapse rate after a patient has stopped natalizumab therapy and switched to dimethyl fumarate.
INDIANAPOLIS—A majority of patients remain stable when switching from natalizumab to dimethyl fumarate, according to data presented at the 2015 CMSC Annual Meeting. Factors such as sex, age, and duration of natalizumab treatment may predict the probability of a successful transition, reported lead author Faria S. Amjad, MD, of Georgetown University Hospital in Washington, DC, and research colleagues.
Natalizumab is a monoclonal antibody that prevents entry of leukocytes into the CNS. This mechanism of action has made it one of the most effective therapies against multiple sclerosis (MS). However, natalizumab’s use is limited by its risk of progressive multifocal leukoencephalopathy (PML). Moreover, switching from natalizumab to another therapeutic agent is made even more complex, as there is an increased risk of rebound inflammation. Dimethyl fumarate is an oral agent that offers a therapeutic alternative to patients stopping natalizumab. However, the safety and efficacy of this switch have not been studied.
To assess the stability of patients switched from natalizumab to dimethyl fumarate, Dr. Amjad and colleagues conducted a telephone survey and chart review for 66 patients with relapsing-remitting MS who had been switched from natalizumab to dimethyl fumarate. Factors analyzed included age, gender, duration on natalizumab, and duration on dimethyl fumarate.
A total of 66 patients were surveyed; 47 (71.22%) remained stable when switched to dimethyl fumarate, and 19 (28.78%) were found to be unstable on dimethyl fumarate. While the findings were not statistically significant, several trends were noted. Female patients were 2.9 times more likely to be unstable, compared with males. Patients younger than 60 were 1.8 times more likely to be unstable, compared with patients older than 60. Patients on natalizumab for less than two years were 2.4 times more likely to be unstable, compared with patients on natulizumab for more than two years. Patients who have an eight-week or less gap between natulizumab and dimethyl fumarate are just as likely to develop instability as patients with more than an eight-week gap between treatments. Patients who are on dimethyl fumarate for less than six months are 0.6 times less likely to be unstable than patients on dimethyl fumarate for longer than six months. In other words, patients on dimethyl fumarate for longer than six months are 1.7 times more likely to be unstable.
According to the researchers, an extension of this study will look at MRI changes and relapse rate after a patient has stopped natalizumab therapy and switched to dimethyl fumarate.
INDIANAPOLIS—A majority of patients remain stable when switching from natalizumab to dimethyl fumarate, according to data presented at the 2015 CMSC Annual Meeting. Factors such as sex, age, and duration of natalizumab treatment may predict the probability of a successful transition, reported lead author Faria S. Amjad, MD, of Georgetown University Hospital in Washington, DC, and research colleagues.
Natalizumab is a monoclonal antibody that prevents entry of leukocytes into the CNS. This mechanism of action has made it one of the most effective therapies against multiple sclerosis (MS). However, natalizumab’s use is limited by its risk of progressive multifocal leukoencephalopathy (PML). Moreover, switching from natalizumab to another therapeutic agent is made even more complex, as there is an increased risk of rebound inflammation. Dimethyl fumarate is an oral agent that offers a therapeutic alternative to patients stopping natalizumab. However, the safety and efficacy of this switch have not been studied.
To assess the stability of patients switched from natalizumab to dimethyl fumarate, Dr. Amjad and colleagues conducted a telephone survey and chart review for 66 patients with relapsing-remitting MS who had been switched from natalizumab to dimethyl fumarate. Factors analyzed included age, gender, duration on natalizumab, and duration on dimethyl fumarate.
A total of 66 patients were surveyed; 47 (71.22%) remained stable when switched to dimethyl fumarate, and 19 (28.78%) were found to be unstable on dimethyl fumarate. While the findings were not statistically significant, several trends were noted. Female patients were 2.9 times more likely to be unstable, compared with males. Patients younger than 60 were 1.8 times more likely to be unstable, compared with patients older than 60. Patients on natalizumab for less than two years were 2.4 times more likely to be unstable, compared with patients on natulizumab for more than two years. Patients who have an eight-week or less gap between natulizumab and dimethyl fumarate are just as likely to develop instability as patients with more than an eight-week gap between treatments. Patients who are on dimethyl fumarate for less than six months are 0.6 times less likely to be unstable than patients on dimethyl fumarate for longer than six months. In other words, patients on dimethyl fumarate for longer than six months are 1.7 times more likely to be unstable.
According to the researchers, an extension of this study will look at MRI changes and relapse rate after a patient has stopped natalizumab therapy and switched to dimethyl fumarate.
Promoting MS Medication Adherence Through Telehealth
INDIANAPOLIS—Self-reported monitoring through an automated telehealth mechanism can provide a valid assessment of disease-modifying therapy (DMT) adherence among patients with multiple sclerosis (MS), according to study findings reported at the 2015 CMSC Annual Meeting. Further, utilizing an automated electronic system reduces the time spent making phone calls and researching pharmacy refill records by healthcare providers, according to Jill R. Settle and her research colleagues. Ms. Settle is affiliated with the MS Center of Excellence at the Veterans Affairs Medical Center in Washington, DC.
DMTs for MS have been available for more than 20 years; however, adherence to DMT regimens is often poor. The most common reason cited by patients is forgetting to take their medications on the specific day they are to be administered. To address the issue of non-adherence, Ms. Settle and colleagues sought to establish the feasibility of implementing a home telehealth program to support and monitor MS medication adherence without increasing healthcare provider burden.
The researchers addressed the assessment of poor adherence using a comprehensive Home Automated Telemanagement system for MS (MS HAT). MS HAT is a home-based Internet module that supports patient self-management, patient–provider communication, and patient education.
For approximately six months, 30 study participants were randomized to either MS HAT or treatment as usual. All participants stored their interferon β-1a syringes in a clear syringe container and maintained a paper calendar of medication adherence. Pharmacy refill rates were also collected from medical records. Participants in the MS HAT study arm received text or e-mail reminders to administer their medication.
There were no significant differences in demographic variables between the two groups. Likewise, overall adherence did not differ between the two groups. MS HAT alert rates were negatively correlated with syringe counts. As alerts decreased, syringes collected increased. Syringe count was positively related to change in Morisky score for interferon β-1a. As self-reported adherence improved, the number of syringes collected also increased. Pharmacy refills were directly related to calendar reports of taking the medication and syringe counts. As pharmacy refills increased, so did calendar reports and syringes collected.
The strong correlation between self-report and objective measures of adherence suggests that the MS HAT system is effective and cost-efficient.
INDIANAPOLIS—Self-reported monitoring through an automated telehealth mechanism can provide a valid assessment of disease-modifying therapy (DMT) adherence among patients with multiple sclerosis (MS), according to study findings reported at the 2015 CMSC Annual Meeting. Further, utilizing an automated electronic system reduces the time spent making phone calls and researching pharmacy refill records by healthcare providers, according to Jill R. Settle and her research colleagues. Ms. Settle is affiliated with the MS Center of Excellence at the Veterans Affairs Medical Center in Washington, DC.
DMTs for MS have been available for more than 20 years; however, adherence to DMT regimens is often poor. The most common reason cited by patients is forgetting to take their medications on the specific day they are to be administered. To address the issue of non-adherence, Ms. Settle and colleagues sought to establish the feasibility of implementing a home telehealth program to support and monitor MS medication adherence without increasing healthcare provider burden.
The researchers addressed the assessment of poor adherence using a comprehensive Home Automated Telemanagement system for MS (MS HAT). MS HAT is a home-based Internet module that supports patient self-management, patient–provider communication, and patient education.
For approximately six months, 30 study participants were randomized to either MS HAT or treatment as usual. All participants stored their interferon β-1a syringes in a clear syringe container and maintained a paper calendar of medication adherence. Pharmacy refill rates were also collected from medical records. Participants in the MS HAT study arm received text or e-mail reminders to administer their medication.
There were no significant differences in demographic variables between the two groups. Likewise, overall adherence did not differ between the two groups. MS HAT alert rates were negatively correlated with syringe counts. As alerts decreased, syringes collected increased. Syringe count was positively related to change in Morisky score for interferon β-1a. As self-reported adherence improved, the number of syringes collected also increased. Pharmacy refills were directly related to calendar reports of taking the medication and syringe counts. As pharmacy refills increased, so did calendar reports and syringes collected.
The strong correlation between self-report and objective measures of adherence suggests that the MS HAT system is effective and cost-efficient.
INDIANAPOLIS—Self-reported monitoring through an automated telehealth mechanism can provide a valid assessment of disease-modifying therapy (DMT) adherence among patients with multiple sclerosis (MS), according to study findings reported at the 2015 CMSC Annual Meeting. Further, utilizing an automated electronic system reduces the time spent making phone calls and researching pharmacy refill records by healthcare providers, according to Jill R. Settle and her research colleagues. Ms. Settle is affiliated with the MS Center of Excellence at the Veterans Affairs Medical Center in Washington, DC.
DMTs for MS have been available for more than 20 years; however, adherence to DMT regimens is often poor. The most common reason cited by patients is forgetting to take their medications on the specific day they are to be administered. To address the issue of non-adherence, Ms. Settle and colleagues sought to establish the feasibility of implementing a home telehealth program to support and monitor MS medication adherence without increasing healthcare provider burden.
The researchers addressed the assessment of poor adherence using a comprehensive Home Automated Telemanagement system for MS (MS HAT). MS HAT is a home-based Internet module that supports patient self-management, patient–provider communication, and patient education.
For approximately six months, 30 study participants were randomized to either MS HAT or treatment as usual. All participants stored their interferon β-1a syringes in a clear syringe container and maintained a paper calendar of medication adherence. Pharmacy refill rates were also collected from medical records. Participants in the MS HAT study arm received text or e-mail reminders to administer their medication.
There were no significant differences in demographic variables between the two groups. Likewise, overall adherence did not differ between the two groups. MS HAT alert rates were negatively correlated with syringe counts. As alerts decreased, syringes collected increased. Syringe count was positively related to change in Morisky score for interferon β-1a. As self-reported adherence improved, the number of syringes collected also increased. Pharmacy refills were directly related to calendar reports of taking the medication and syringe counts. As pharmacy refills increased, so did calendar reports and syringes collected.
The strong correlation between self-report and objective measures of adherence suggests that the MS HAT system is effective and cost-efficient.
How Should Neurologists Treat Menopausal Women With MS?
INDIANAPOLIS—Although many women with multiple sclerosis (MS) are perimenopausal, the literature contains few data about effective ways to manage these women’s symptoms, according to research presented at the 2015 CMSC Annual Meeting. The topic could be considered to inhabit an “evidence-free zone,” but general recommendations are possible, according to Riley Bove, MD, Instructor at Harvard Medical School in Boston.
During menopause, women may have vasomotor symptoms such as hot flashes, vascular instability, and rapid heartbeat. For patients with MS, these symptoms may disturb sleep, contribute to fatigue, and affect mood. Vasomotor symptoms also may cause exacerbations. Hormone replacement therapy is the most effective treatment for vasomotor symptoms. In the Women’s Health Initiative Memory Study, however, hormone replacement therapy initiated in women age 65 or older was associated with an increased risk of dementia and cognitive decline. This association should be examined in longitudinal placebo-controlled trials, said Dr. Bove.
Bladder symptoms and sleep apnea are more common during menopause and can cause frequent awakenings, which lead to mood disturbances (eg, depression or anxiety) and relational problems in patients with MS. To improve sleep, neurologists should advise their patients about good sleep hygiene. Patients should stay in bed for only a certain amount of time, use their bed for sleep or intimacy only, schedule regular wake times, and moderate caffeine intake, among other behaviors.
Fatigue is common in MS, and its severity and frequency tend to increase during menopause. Neurologists should rule out additional contributors to fatigue, such as thyroid disease. Patients should be advised to arrange their daily schedule so that work routines are spaced out. They should take intermittent rest breaks and try to concentrate their activity in the morning when it is cooler. Relaxation and meditation practices can reduce stress and decrease fatigue. Drugs such as modafinil and amantadine can promote wakefulness, and methylphenidate can be used as a stimulant.
Pain tolerance may decrease during menopause, and patients with MS often have cervical and lumbar spondylosis, joint immobility, spasticity, and deconditioning. Baclofen, diazepam, dantrolene, and tizanidine may be effective for pain resulting from spasticity. Phenytoin, carbamazepine, and tricyclic antidepressants can alleviate neuropathic pain and paresthesias. Neurologists also might recommend weight loss or exercise or refer a patient to a pain center for an integrated approach to the condition.
Mood disorders are common among patients with MS, and mood fluctuations may accompany menopause. In response to this problem, a neurologist may recommend psychotherapy to help optimize the patient’s coping abilities. Spousal and interpersonal support also are important for the patient. Antidepressants such as fluoxetine, sertraline, escitalopram, and citalopram can be effective if drug therapy is warranted. Support groups also may help stabilize the patient’s mood.
—Erik Greb
INDIANAPOLIS—Although many women with multiple sclerosis (MS) are perimenopausal, the literature contains few data about effective ways to manage these women’s symptoms, according to research presented at the 2015 CMSC Annual Meeting. The topic could be considered to inhabit an “evidence-free zone,” but general recommendations are possible, according to Riley Bove, MD, Instructor at Harvard Medical School in Boston.
During menopause, women may have vasomotor symptoms such as hot flashes, vascular instability, and rapid heartbeat. For patients with MS, these symptoms may disturb sleep, contribute to fatigue, and affect mood. Vasomotor symptoms also may cause exacerbations. Hormone replacement therapy is the most effective treatment for vasomotor symptoms. In the Women’s Health Initiative Memory Study, however, hormone replacement therapy initiated in women age 65 or older was associated with an increased risk of dementia and cognitive decline. This association should be examined in longitudinal placebo-controlled trials, said Dr. Bove.
Bladder symptoms and sleep apnea are more common during menopause and can cause frequent awakenings, which lead to mood disturbances (eg, depression or anxiety) and relational problems in patients with MS. To improve sleep, neurologists should advise their patients about good sleep hygiene. Patients should stay in bed for only a certain amount of time, use their bed for sleep or intimacy only, schedule regular wake times, and moderate caffeine intake, among other behaviors.
Fatigue is common in MS, and its severity and frequency tend to increase during menopause. Neurologists should rule out additional contributors to fatigue, such as thyroid disease. Patients should be advised to arrange their daily schedule so that work routines are spaced out. They should take intermittent rest breaks and try to concentrate their activity in the morning when it is cooler. Relaxation and meditation practices can reduce stress and decrease fatigue. Drugs such as modafinil and amantadine can promote wakefulness, and methylphenidate can be used as a stimulant.
Pain tolerance may decrease during menopause, and patients with MS often have cervical and lumbar spondylosis, joint immobility, spasticity, and deconditioning. Baclofen, diazepam, dantrolene, and tizanidine may be effective for pain resulting from spasticity. Phenytoin, carbamazepine, and tricyclic antidepressants can alleviate neuropathic pain and paresthesias. Neurologists also might recommend weight loss or exercise or refer a patient to a pain center for an integrated approach to the condition.
Mood disorders are common among patients with MS, and mood fluctuations may accompany menopause. In response to this problem, a neurologist may recommend psychotherapy to help optimize the patient’s coping abilities. Spousal and interpersonal support also are important for the patient. Antidepressants such as fluoxetine, sertraline, escitalopram, and citalopram can be effective if drug therapy is warranted. Support groups also may help stabilize the patient’s mood.
—Erik Greb
INDIANAPOLIS—Although many women with multiple sclerosis (MS) are perimenopausal, the literature contains few data about effective ways to manage these women’s symptoms, according to research presented at the 2015 CMSC Annual Meeting. The topic could be considered to inhabit an “evidence-free zone,” but general recommendations are possible, according to Riley Bove, MD, Instructor at Harvard Medical School in Boston.
During menopause, women may have vasomotor symptoms such as hot flashes, vascular instability, and rapid heartbeat. For patients with MS, these symptoms may disturb sleep, contribute to fatigue, and affect mood. Vasomotor symptoms also may cause exacerbations. Hormone replacement therapy is the most effective treatment for vasomotor symptoms. In the Women’s Health Initiative Memory Study, however, hormone replacement therapy initiated in women age 65 or older was associated with an increased risk of dementia and cognitive decline. This association should be examined in longitudinal placebo-controlled trials, said Dr. Bove.
Bladder symptoms and sleep apnea are more common during menopause and can cause frequent awakenings, which lead to mood disturbances (eg, depression or anxiety) and relational problems in patients with MS. To improve sleep, neurologists should advise their patients about good sleep hygiene. Patients should stay in bed for only a certain amount of time, use their bed for sleep or intimacy only, schedule regular wake times, and moderate caffeine intake, among other behaviors.
Fatigue is common in MS, and its severity and frequency tend to increase during menopause. Neurologists should rule out additional contributors to fatigue, such as thyroid disease. Patients should be advised to arrange their daily schedule so that work routines are spaced out. They should take intermittent rest breaks and try to concentrate their activity in the morning when it is cooler. Relaxation and meditation practices can reduce stress and decrease fatigue. Drugs such as modafinil and amantadine can promote wakefulness, and methylphenidate can be used as a stimulant.
Pain tolerance may decrease during menopause, and patients with MS often have cervical and lumbar spondylosis, joint immobility, spasticity, and deconditioning. Baclofen, diazepam, dantrolene, and tizanidine may be effective for pain resulting from spasticity. Phenytoin, carbamazepine, and tricyclic antidepressants can alleviate neuropathic pain and paresthesias. Neurologists also might recommend weight loss or exercise or refer a patient to a pain center for an integrated approach to the condition.
Mood disorders are common among patients with MS, and mood fluctuations may accompany menopause. In response to this problem, a neurologist may recommend psychotherapy to help optimize the patient’s coping abilities. Spousal and interpersonal support also are important for the patient. Antidepressants such as fluoxetine, sertraline, escitalopram, and citalopram can be effective if drug therapy is warranted. Support groups also may help stabilize the patient’s mood.
—Erik Greb
VIDEO: Cannabis further compromises cognitive function in some MS patients
INDIANAPOLIS – Although an estimated 10%-20% of multiple sclerosis patients currently smoke cannabis for pain control or to alleviate symptoms, new research from Canada suggests that smoking the drug can worsen cognitive function in some patients with the disease.
“We already know that 40%-70% of people with MS already have cognitive problems,” Dr. Anthony Feinstein, professor of psychiatrist at the University of Toronto, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. “Some of the research that I’ve done shows that, in the presence of cannabis, these rates go up.”
Even so, he emphasized that patients should weigh such side effects against the benefits of use.
“I think it’s going to be an individual decision,” he said. “If it’s helping with pain, that’s good. Our data needs to be replicated by other groups.”
Dr. Feinstein disclosed that his work on MS and cannabis is funded by the Multiple Sclerosis Society of Canada.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @dougbrunk
INDIANAPOLIS – Although an estimated 10%-20% of multiple sclerosis patients currently smoke cannabis for pain control or to alleviate symptoms, new research from Canada suggests that smoking the drug can worsen cognitive function in some patients with the disease.
“We already know that 40%-70% of people with MS already have cognitive problems,” Dr. Anthony Feinstein, professor of psychiatrist at the University of Toronto, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. “Some of the research that I’ve done shows that, in the presence of cannabis, these rates go up.”
Even so, he emphasized that patients should weigh such side effects against the benefits of use.
“I think it’s going to be an individual decision,” he said. “If it’s helping with pain, that’s good. Our data needs to be replicated by other groups.”
Dr. Feinstein disclosed that his work on MS and cannabis is funded by the Multiple Sclerosis Society of Canada.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @dougbrunk
INDIANAPOLIS – Although an estimated 10%-20% of multiple sclerosis patients currently smoke cannabis for pain control or to alleviate symptoms, new research from Canada suggests that smoking the drug can worsen cognitive function in some patients with the disease.
“We already know that 40%-70% of people with MS already have cognitive problems,” Dr. Anthony Feinstein, professor of psychiatrist at the University of Toronto, said in a video interview at the annual meeting of the Consortium of Multiple Sclerosis Centers. “Some of the research that I’ve done shows that, in the presence of cannabis, these rates go up.”
Even so, he emphasized that patients should weigh such side effects against the benefits of use.
“I think it’s going to be an individual decision,” he said. “If it’s helping with pain, that’s good. Our data needs to be replicated by other groups.”
Dr. Feinstein disclosed that his work on MS and cannabis is funded by the Multiple Sclerosis Society of Canada.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @dougbrunk
AT THE CMSC ANNUAL MEETING
Early Detection of PML May Improve Outcomes
INDIANAPOLIS—Early detection of progressive multifocal leukoencephalopathy (PML) may improve outcomes, according to an update presented at the 2015 CMSC Annual Meeting. When PML results from reversible immunosuppression, as in patients with multiple sclerosis (MS) who are receiving monoclonal antibodies, the immediate cessation of the offending agent is recommended.
The pathogenesis of PML is not well understood, but the initial infection may be oropharyngeal or respiratory, said Joseph R. Berger, MD, Professor of Neurology at the Hospital of the University of Pennsylvania in Philadelphia. The infection spreads to sites of latency and may be re-expressed with circulation in B cells before entering the CNS.
As of March 3, 2015, 541 cases of PML have been reported in patients receiving natalizumab. Of these patients, 538 had MS. The patients’ mean duration of treatment with natalizumab was 42 months. Approximately 8% of patients were a-symptomatic at the time of diagnosis. Data have suggested that exposure to John Cunningham virus (JCV), prior immunosuppressive therapy, and longer treatment duration are risk factors for PML.
Since 2013, New England Journal of Medicine has published three case reports of PML in patients receiving dimethyl fumarate. In one of the cases, the drug had been manufactured by a compounding pharmacy. The literature also contains two cases of PML in patients receiving fingolimod.
To date, 160 cases of PML have been reported in patients receiving rituximab, but none of these cases occurred in patients with MS. Almost all cases of PML related to rituximab were in patients with chronic lymphocytic leukemia or other lymphoproliferative diseases. The drug has a black box warning, but the risk of PML for patients receiving this therapy probably is “vanishingly low,” said Dr. Berger.
A total of 57 patients receiving alemtuzumab have developed PML. Fifty-five of these individuals had chronic lymphocytic leukemia, and two developed PML after a lung transplant. Alemtuzumab depletes B cells, which recover in 27 months, and T cells, which recover in 61 months.
Diagnosis of PML depends on neuropathologic demonstration of demyelination, bizarre astrocytes, and enlarged oligodendroglial nuclei. The presence of JCV also must be established by polymerase chain reaction. A two-step Enzyme Linked Immunosorbent Assay can detect JCV antibodies, but it has a significant risk of false seronegativity, said Dr. Berger.
On CT imaging, PML manifests as hypodense lesions and, in less than 10% of cases, as contrast enhancement. PML is visible as hypointense lesions on T1 MRI and as increased signal on T2 MRI and FLAIR. PML is not associated with mass effect on MRI and often affects parieto-occipital and frontal lobes. The condition may affect atypical locations such as the cerebellum, brainstem, basal ganglia, or temporal lobe.
—Erik Greb
Suggested Reading
Carruthers RL, Berger J. Progressive multifocal leukoencephalopathy and JC Virus-related disease in modern neurology practice. Mult Scler Relat Disord. 2014;3(4):419-430.
INDIANAPOLIS—Early detection of progressive multifocal leukoencephalopathy (PML) may improve outcomes, according to an update presented at the 2015 CMSC Annual Meeting. When PML results from reversible immunosuppression, as in patients with multiple sclerosis (MS) who are receiving monoclonal antibodies, the immediate cessation of the offending agent is recommended.
The pathogenesis of PML is not well understood, but the initial infection may be oropharyngeal or respiratory, said Joseph R. Berger, MD, Professor of Neurology at the Hospital of the University of Pennsylvania in Philadelphia. The infection spreads to sites of latency and may be re-expressed with circulation in B cells before entering the CNS.
As of March 3, 2015, 541 cases of PML have been reported in patients receiving natalizumab. Of these patients, 538 had MS. The patients’ mean duration of treatment with natalizumab was 42 months. Approximately 8% of patients were a-symptomatic at the time of diagnosis. Data have suggested that exposure to John Cunningham virus (JCV), prior immunosuppressive therapy, and longer treatment duration are risk factors for PML.
Since 2013, New England Journal of Medicine has published three case reports of PML in patients receiving dimethyl fumarate. In one of the cases, the drug had been manufactured by a compounding pharmacy. The literature also contains two cases of PML in patients receiving fingolimod.
To date, 160 cases of PML have been reported in patients receiving rituximab, but none of these cases occurred in patients with MS. Almost all cases of PML related to rituximab were in patients with chronic lymphocytic leukemia or other lymphoproliferative diseases. The drug has a black box warning, but the risk of PML for patients receiving this therapy probably is “vanishingly low,” said Dr. Berger.
A total of 57 patients receiving alemtuzumab have developed PML. Fifty-five of these individuals had chronic lymphocytic leukemia, and two developed PML after a lung transplant. Alemtuzumab depletes B cells, which recover in 27 months, and T cells, which recover in 61 months.
Diagnosis of PML depends on neuropathologic demonstration of demyelination, bizarre astrocytes, and enlarged oligodendroglial nuclei. The presence of JCV also must be established by polymerase chain reaction. A two-step Enzyme Linked Immunosorbent Assay can detect JCV antibodies, but it has a significant risk of false seronegativity, said Dr. Berger.
On CT imaging, PML manifests as hypodense lesions and, in less than 10% of cases, as contrast enhancement. PML is visible as hypointense lesions on T1 MRI and as increased signal on T2 MRI and FLAIR. PML is not associated with mass effect on MRI and often affects parieto-occipital and frontal lobes. The condition may affect atypical locations such as the cerebellum, brainstem, basal ganglia, or temporal lobe.
—Erik Greb
INDIANAPOLIS—Early detection of progressive multifocal leukoencephalopathy (PML) may improve outcomes, according to an update presented at the 2015 CMSC Annual Meeting. When PML results from reversible immunosuppression, as in patients with multiple sclerosis (MS) who are receiving monoclonal antibodies, the immediate cessation of the offending agent is recommended.
The pathogenesis of PML is not well understood, but the initial infection may be oropharyngeal or respiratory, said Joseph R. Berger, MD, Professor of Neurology at the Hospital of the University of Pennsylvania in Philadelphia. The infection spreads to sites of latency and may be re-expressed with circulation in B cells before entering the CNS.
As of March 3, 2015, 541 cases of PML have been reported in patients receiving natalizumab. Of these patients, 538 had MS. The patients’ mean duration of treatment with natalizumab was 42 months. Approximately 8% of patients were a-symptomatic at the time of diagnosis. Data have suggested that exposure to John Cunningham virus (JCV), prior immunosuppressive therapy, and longer treatment duration are risk factors for PML.
Since 2013, New England Journal of Medicine has published three case reports of PML in patients receiving dimethyl fumarate. In one of the cases, the drug had been manufactured by a compounding pharmacy. The literature also contains two cases of PML in patients receiving fingolimod.
To date, 160 cases of PML have been reported in patients receiving rituximab, but none of these cases occurred in patients with MS. Almost all cases of PML related to rituximab were in patients with chronic lymphocytic leukemia or other lymphoproliferative diseases. The drug has a black box warning, but the risk of PML for patients receiving this therapy probably is “vanishingly low,” said Dr. Berger.
A total of 57 patients receiving alemtuzumab have developed PML. Fifty-five of these individuals had chronic lymphocytic leukemia, and two developed PML after a lung transplant. Alemtuzumab depletes B cells, which recover in 27 months, and T cells, which recover in 61 months.
Diagnosis of PML depends on neuropathologic demonstration of demyelination, bizarre astrocytes, and enlarged oligodendroglial nuclei. The presence of JCV also must be established by polymerase chain reaction. A two-step Enzyme Linked Immunosorbent Assay can detect JCV antibodies, but it has a significant risk of false seronegativity, said Dr. Berger.
On CT imaging, PML manifests as hypodense lesions and, in less than 10% of cases, as contrast enhancement. PML is visible as hypointense lesions on T1 MRI and as increased signal on T2 MRI and FLAIR. PML is not associated with mass effect on MRI and often affects parieto-occipital and frontal lobes. The condition may affect atypical locations such as the cerebellum, brainstem, basal ganglia, or temporal lobe.
—Erik Greb
Suggested Reading
Carruthers RL, Berger J. Progressive multifocal leukoencephalopathy and JC Virus-related disease in modern neurology practice. Mult Scler Relat Disord. 2014;3(4):419-430.
Suggested Reading
Carruthers RL, Berger J. Progressive multifocal leukoencephalopathy and JC Virus-related disease in modern neurology practice. Mult Scler Relat Disord. 2014;3(4):419-430.
Smoked Cannabis May Impair Cognition in Patients With MS
INDIANAPOLIS—Smoked cannabis may compromise cognitive function in patients with multiple sclerosis (MS), according to an overview presented at the 2015 Consortium of MS Centers Annual Meeting. Evidence does not support the hypothesis that cannabis affects mood or causes anxiety or psychosis, however. Clinicians should weigh the potentially harmful effects of cannabis on cognition against the drug’s possible benefits for pain, spasticity, and urinary problems.
Between 40% and 70% of people with MS have cognitive dysfunction, which may include deficits in information processing speed, working memory, visuospatial memory, or executive function, said Anthony Feinstein, MD, PhD, Professor of Psychiatry at the University of Toronto. Approximately 40% of patients with MS have used cannabis, and Dr. Feinstein studies the drug’s effects on cognition among patients with MS.
In 2008, he and his colleagues interviewed 140 consecutive patients with MS with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Axis I disorders. The researchers assessed cognition using the Neuropsychological Battery for MS, supplemented with the Symbol Digit Modalities Test (SDMT). When the investigators compared 10 current cannabis users with 40 matched controls with MS, they found that cannabis users had a slower mean performance time on the SDMT and a different pattern of response, compared with the matched controls.
In 2011, Dr. Feinstein and colleagues compared 25 patients with MS who smoked cannabis with 25 patients with MS who did not smoke cannabis. Participants underwent the Minimal Assessment of Cognitive Function in MS battery of neuropsychologic tests, the Hospital Anxiety and Depression Scale (HADS), and the Structured Clinical Interview for the DSM-IV Axis I Disorders. The two patient groups were matched for demographic and disease variables. Cannabis users were more likely to be unemployed than nonusers and also had more cognitive deficits, including in visuospatial perception, executive function, and information processing speed, compared with nonusers. The researchers found no differences between groups in depression or anxiety, however.
Finally, in 2014, Dr. Feinstein and colleagues performed a cross-sectional study of 20 patients with MS who smoked cannabis and 19 patients with MS who did not. Participants underwent fMRI while completing the N-Back test of working memory. Spatial memory and Paced Auditory Serial Addition Test scores were lower among patients who smoked cannabis. These patients also had slowed responses and more errors on the N-Back test, compared with cannabis nonusers. During this test, cannabis users also had increased activation in parietal and anterior cingulate regions implicated in working memory, compared with nonusers.
—Erik Greb
INDIANAPOLIS—Smoked cannabis may compromise cognitive function in patients with multiple sclerosis (MS), according to an overview presented at the 2015 Consortium of MS Centers Annual Meeting. Evidence does not support the hypothesis that cannabis affects mood or causes anxiety or psychosis, however. Clinicians should weigh the potentially harmful effects of cannabis on cognition against the drug’s possible benefits for pain, spasticity, and urinary problems.
Between 40% and 70% of people with MS have cognitive dysfunction, which may include deficits in information processing speed, working memory, visuospatial memory, or executive function, said Anthony Feinstein, MD, PhD, Professor of Psychiatry at the University of Toronto. Approximately 40% of patients with MS have used cannabis, and Dr. Feinstein studies the drug’s effects on cognition among patients with MS.
In 2008, he and his colleagues interviewed 140 consecutive patients with MS with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Axis I disorders. The researchers assessed cognition using the Neuropsychological Battery for MS, supplemented with the Symbol Digit Modalities Test (SDMT). When the investigators compared 10 current cannabis users with 40 matched controls with MS, they found that cannabis users had a slower mean performance time on the SDMT and a different pattern of response, compared with the matched controls.
In 2011, Dr. Feinstein and colleagues compared 25 patients with MS who smoked cannabis with 25 patients with MS who did not smoke cannabis. Participants underwent the Minimal Assessment of Cognitive Function in MS battery of neuropsychologic tests, the Hospital Anxiety and Depression Scale (HADS), and the Structured Clinical Interview for the DSM-IV Axis I Disorders. The two patient groups were matched for demographic and disease variables. Cannabis users were more likely to be unemployed than nonusers and also had more cognitive deficits, including in visuospatial perception, executive function, and information processing speed, compared with nonusers. The researchers found no differences between groups in depression or anxiety, however.
Finally, in 2014, Dr. Feinstein and colleagues performed a cross-sectional study of 20 patients with MS who smoked cannabis and 19 patients with MS who did not. Participants underwent fMRI while completing the N-Back test of working memory. Spatial memory and Paced Auditory Serial Addition Test scores were lower among patients who smoked cannabis. These patients also had slowed responses and more errors on the N-Back test, compared with cannabis nonusers. During this test, cannabis users also had increased activation in parietal and anterior cingulate regions implicated in working memory, compared with nonusers.
—Erik Greb
INDIANAPOLIS—Smoked cannabis may compromise cognitive function in patients with multiple sclerosis (MS), according to an overview presented at the 2015 Consortium of MS Centers Annual Meeting. Evidence does not support the hypothesis that cannabis affects mood or causes anxiety or psychosis, however. Clinicians should weigh the potentially harmful effects of cannabis on cognition against the drug’s possible benefits for pain, spasticity, and urinary problems.
Between 40% and 70% of people with MS have cognitive dysfunction, which may include deficits in information processing speed, working memory, visuospatial memory, or executive function, said Anthony Feinstein, MD, PhD, Professor of Psychiatry at the University of Toronto. Approximately 40% of patients with MS have used cannabis, and Dr. Feinstein studies the drug’s effects on cognition among patients with MS.
In 2008, he and his colleagues interviewed 140 consecutive patients with MS with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Axis I disorders. The researchers assessed cognition using the Neuropsychological Battery for MS, supplemented with the Symbol Digit Modalities Test (SDMT). When the investigators compared 10 current cannabis users with 40 matched controls with MS, they found that cannabis users had a slower mean performance time on the SDMT and a different pattern of response, compared with the matched controls.
In 2011, Dr. Feinstein and colleagues compared 25 patients with MS who smoked cannabis with 25 patients with MS who did not smoke cannabis. Participants underwent the Minimal Assessment of Cognitive Function in MS battery of neuropsychologic tests, the Hospital Anxiety and Depression Scale (HADS), and the Structured Clinical Interview for the DSM-IV Axis I Disorders. The two patient groups were matched for demographic and disease variables. Cannabis users were more likely to be unemployed than nonusers and also had more cognitive deficits, including in visuospatial perception, executive function, and information processing speed, compared with nonusers. The researchers found no differences between groups in depression or anxiety, however.
Finally, in 2014, Dr. Feinstein and colleagues performed a cross-sectional study of 20 patients with MS who smoked cannabis and 19 patients with MS who did not. Participants underwent fMRI while completing the N-Back test of working memory. Spatial memory and Paced Auditory Serial Addition Test scores were lower among patients who smoked cannabis. These patients also had slowed responses and more errors on the N-Back test, compared with cannabis nonusers. During this test, cannabis users also had increased activation in parietal and anterior cingulate regions implicated in working memory, compared with nonusers.
—Erik Greb
Revised Standardized MRI Protocol for the Diagnosis and Follow-Up of MS
INDIANAPOLIS—A standardized MRI is important for the diagnosis and follow-up of patients with multiple sclerosis (MS). However, acquisition and interpretation of MRI scans may be complicated due to differences in pulse sequence (eg, FLAIR vs PD/T2), the use of contiguous and thinner (eg, 3 mm vs 5 mm) slices, as well as different patient positioning. Therefore, the Consortium of Multiple Sclerosis Centers (CMSC) convened a task force to develop and periodically revise indications and guidelines for a standardized MRI protocol in the diagnosis and follow-up of patients with MS. The panel’s most recent recommendations were presented at the 2015 CMSC Annual Meeting and will be published in an upcoming issue of American Journal of Neuroradiology.
Lead author Anthony Traboulsee, MD, Associate Professor at the University of British Columbia in Vancouver, and colleagues reported that a standardized brain MRI protocol with gadolinium is recommended for the diagnosis of MS. A spinal cord MRI is additionally recommended if the brain MRI is nondiagnostic or if the presenting symptoms are at the level of the spinal cord. A follow-up brain MRI with gadolinium is recommended to demonstrate dissemination in time and ongoing clinically silent disease activity while on treatment, to evaluate unexpected clinical worsening, to re-assess the original diagnosis, and as a new baseline prior to starting or modifying therapy. A routine brain MRI should be considered every six months to two years for all patients with relapsing MS. The standardized brain MRI protocol includes 3D T1-weighted, 3D T2-FLAIR (fluid-attenuated inversion recovery), 3D T2-weighted, post single-dose gadolinium-enhanced T1-weighted, and a diffusion-weighted sequence.
According to the 2015 Revised CMSC MRI Protocol, a simplified progressive multifocal leukoencephalopathy (PML) surveillance protocol includes FLAIR and diffusion-weighted imaging sequences only.
The spinal cord MRI protocol includes sagittal T1-weighted and proton density, short-time inversion recovery (STIR) or phase-sensitive inversion recovery (PSIR), axial T2- or T2*-weighted through suspicious lesions, and, in some cases, post-contrast gadolinium-enhanced T1-weighted imaging.
The task force’s revised guideline specifies that the clinical question being addressed should be provided in the requisition for the MRI. The radiology report should be descriptive with results referenced to previous studies. MRI studies should be permanently retained and available.
The 2015 revision incorporates new information and practice recommendations, and modification as modern imaging techniques (eg, 3D) have become more robust and available.
Key changes to the MRI protocol since the last revision in 2006 include an emphasis on 3D sequences for brain MRI, a PML-specific monitoring protocol, and an optional orbit MRI protocol for severe optic neuritis.
Key changes to the clinical guidelines since the 2006 revision include more specific guidance on timing of brain MRI for patients on disease-modifying therapy, timing of brain MRI for PML surveillance, updated evidence on the value of MRI changes in determining treatment effectiveness, and inclusion of radiologically isolated syndrome.
INDIANAPOLIS—A standardized MRI is important for the diagnosis and follow-up of patients with multiple sclerosis (MS). However, acquisition and interpretation of MRI scans may be complicated due to differences in pulse sequence (eg, FLAIR vs PD/T2), the use of contiguous and thinner (eg, 3 mm vs 5 mm) slices, as well as different patient positioning. Therefore, the Consortium of Multiple Sclerosis Centers (CMSC) convened a task force to develop and periodically revise indications and guidelines for a standardized MRI protocol in the diagnosis and follow-up of patients with MS. The panel’s most recent recommendations were presented at the 2015 CMSC Annual Meeting and will be published in an upcoming issue of American Journal of Neuroradiology.
Lead author Anthony Traboulsee, MD, Associate Professor at the University of British Columbia in Vancouver, and colleagues reported that a standardized brain MRI protocol with gadolinium is recommended for the diagnosis of MS. A spinal cord MRI is additionally recommended if the brain MRI is nondiagnostic or if the presenting symptoms are at the level of the spinal cord. A follow-up brain MRI with gadolinium is recommended to demonstrate dissemination in time and ongoing clinically silent disease activity while on treatment, to evaluate unexpected clinical worsening, to re-assess the original diagnosis, and as a new baseline prior to starting or modifying therapy. A routine brain MRI should be considered every six months to two years for all patients with relapsing MS. The standardized brain MRI protocol includes 3D T1-weighted, 3D T2-FLAIR (fluid-attenuated inversion recovery), 3D T2-weighted, post single-dose gadolinium-enhanced T1-weighted, and a diffusion-weighted sequence.
According to the 2015 Revised CMSC MRI Protocol, a simplified progressive multifocal leukoencephalopathy (PML) surveillance protocol includes FLAIR and diffusion-weighted imaging sequences only.
The spinal cord MRI protocol includes sagittal T1-weighted and proton density, short-time inversion recovery (STIR) or phase-sensitive inversion recovery (PSIR), axial T2- or T2*-weighted through suspicious lesions, and, in some cases, post-contrast gadolinium-enhanced T1-weighted imaging.
The task force’s revised guideline specifies that the clinical question being addressed should be provided in the requisition for the MRI. The radiology report should be descriptive with results referenced to previous studies. MRI studies should be permanently retained and available.
The 2015 revision incorporates new information and practice recommendations, and modification as modern imaging techniques (eg, 3D) have become more robust and available.
Key changes to the MRI protocol since the last revision in 2006 include an emphasis on 3D sequences for brain MRI, a PML-specific monitoring protocol, and an optional orbit MRI protocol for severe optic neuritis.
Key changes to the clinical guidelines since the 2006 revision include more specific guidance on timing of brain MRI for patients on disease-modifying therapy, timing of brain MRI for PML surveillance, updated evidence on the value of MRI changes in determining treatment effectiveness, and inclusion of radiologically isolated syndrome.
INDIANAPOLIS—A standardized MRI is important for the diagnosis and follow-up of patients with multiple sclerosis (MS). However, acquisition and interpretation of MRI scans may be complicated due to differences in pulse sequence (eg, FLAIR vs PD/T2), the use of contiguous and thinner (eg, 3 mm vs 5 mm) slices, as well as different patient positioning. Therefore, the Consortium of Multiple Sclerosis Centers (CMSC) convened a task force to develop and periodically revise indications and guidelines for a standardized MRI protocol in the diagnosis and follow-up of patients with MS. The panel’s most recent recommendations were presented at the 2015 CMSC Annual Meeting and will be published in an upcoming issue of American Journal of Neuroradiology.
Lead author Anthony Traboulsee, MD, Associate Professor at the University of British Columbia in Vancouver, and colleagues reported that a standardized brain MRI protocol with gadolinium is recommended for the diagnosis of MS. A spinal cord MRI is additionally recommended if the brain MRI is nondiagnostic or if the presenting symptoms are at the level of the spinal cord. A follow-up brain MRI with gadolinium is recommended to demonstrate dissemination in time and ongoing clinically silent disease activity while on treatment, to evaluate unexpected clinical worsening, to re-assess the original diagnosis, and as a new baseline prior to starting or modifying therapy. A routine brain MRI should be considered every six months to two years for all patients with relapsing MS. The standardized brain MRI protocol includes 3D T1-weighted, 3D T2-FLAIR (fluid-attenuated inversion recovery), 3D T2-weighted, post single-dose gadolinium-enhanced T1-weighted, and a diffusion-weighted sequence.
According to the 2015 Revised CMSC MRI Protocol, a simplified progressive multifocal leukoencephalopathy (PML) surveillance protocol includes FLAIR and diffusion-weighted imaging sequences only.
The spinal cord MRI protocol includes sagittal T1-weighted and proton density, short-time inversion recovery (STIR) or phase-sensitive inversion recovery (PSIR), axial T2- or T2*-weighted through suspicious lesions, and, in some cases, post-contrast gadolinium-enhanced T1-weighted imaging.
The task force’s revised guideline specifies that the clinical question being addressed should be provided in the requisition for the MRI. The radiology report should be descriptive with results referenced to previous studies. MRI studies should be permanently retained and available.
The 2015 revision incorporates new information and practice recommendations, and modification as modern imaging techniques (eg, 3D) have become more robust and available.
Key changes to the MRI protocol since the last revision in 2006 include an emphasis on 3D sequences for brain MRI, a PML-specific monitoring protocol, and an optional orbit MRI protocol for severe optic neuritis.
Key changes to the clinical guidelines since the 2006 revision include more specific guidance on timing of brain MRI for patients on disease-modifying therapy, timing of brain MRI for PML surveillance, updated evidence on the value of MRI changes in determining treatment effectiveness, and inclusion of radiologically isolated syndrome.