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Early Treatment Improves Outcomes in Neuromyelitis Optica Spectrum Disorder
Research has improved understanding of the disorder’s pathology and indicated which treatments are most beneficial.
HILTON HEAD, SC—Neuromyelitis optica spectrum disorder (NMOSD) can result in severe disability, but early diagnosis and treatment increase the likelihood that a patient will regain his or her baseline function, according to an overview provided at the 41st Annual Contemporary Clinical Neurology Symposium. Increased understanding of NMOSD has led to new diagnostic criteria, and emerging data are clarifying the question of effective treatments.
NMOSD As a Distinct Disorder
NMOSD originally was recognized as an inflammatory disorder of the CNS that causes transverse myelitis and optic neuritis, said Siddharama Pawate, MD, Associate Professor of Neurology at Vanderbilt University Medical Center in Nashville. Although neurologists first considered NMOSD a variant of multiple sclerosis (MS), the former has several features that distinguish it from the latter. These features include exceptionally severe relapses, spinal cord lesions that span more than three vertebral segments, and CSF that reveals pleocytosis and high protein levels. In addition, some MS treatments such as interferons, fingolimod, and natalizumab usually exacerbate, rather than mitigate, NMOSD.
In 2004, researchers found that antibodies against aquaporin-4 (AQP4) were almost 100% specific for NMOSD. Astrocytes and ependymal cells, but not oligodendrocytes or neurons, express AQP4. When anti-AQP4 antibodies bind to the membrane of an astrocyte, they disrupt the blood–brain barrier and eventually cause the astrocyte to die. The death of astrocytes promotes secondary damage of oligodendrocytes and neurons. Because of these processes, swelling in the spinal cord and the optic nerve are prominent features of NMOSD on MRI, said Dr. Pawate. The swelling, in turn, can lead to vascular compromise and necrosis, thus
Clinical Presentations of NMOSD
Approximately 75% of patients with NMOSD present with optic neuritis. The next most common clinical presentation is transverse myelitis, which may include paraparesis or quadriparesis, loss of sensation, and bladder or bowel dysfunction. About 35% of patients present with transverse myelitis. Optic neuritis and transverse myelitis occur simultaneously in about 10% of patients who present with NMOSD. “Unlike the MS lesions that are mostly in the white matter, NMOSD lesions in the spinal cord involve gray matter and white matter,” said Dr. Pawate. Other clinical features specific to NMOSD include severe neuropathic pain, tonic spasms that last for as long as 90 seconds, and pruritus. The latter symptom responds well to gabapentin, said Dr. Pawate.
NMOSD entails more severe optic neuritis than that associated with MS. It can be bilateral and lead to complete loss of vision. Optic neuritis usually is longitudinally extensive in NMOSD. A lesion length of 17.6 mm suffices to distinguish NMOSD from MS, and a length of more than 35 mm is approximately 100% specific for the former disorder. Swelling can cause necrosis in the optic nerve and result in poor recovery of vision. Furthermore, homonymous hemianopsia can happen in NMOSD due to damage to the optic tracts, but is rare in MS.
The clinical presentation of NMOSD also may include area postrema syndrome, which entails intractable nausea and vomiting. Patients may have cerebral or cerebellar lesions, symptomatic narcolepsy, or endocrine dysfunction (eg, syndrome of inappropriate antidiuretic hormone secretion).
The 2015 Diagnostic Criteria
Deepening understanding of NMOSD led to the development of new diagnostic criteria in 2015. The criteria identify optic neuritis, acute myelitis, area postrema syndrome, acute brainstem syndrome, symptomatic narcolepsy or acute diencephalic syndrome with MRI lesions typical of NMOSD, and symptomatic cerebral syndrome with MRI lesions typical of NMOSD as the six core clinical characteristics. If the patient tests positive for AQP4 antibodies and has one core clinical characteristic, a diagnosis of NMOSD is appropriate. If the patient tests negative for AQP4 antibodies, he or she must have two or more core clinical characteristics (at least one of which should be optic neuritis, acute myelitis, or area postrema syndrome) that are disseminated in space for a diagnosis of NMOSD to be appropriate. In both cases, alternative diagnoses also must be excluded.
Some patients who test negative for AQP4 antibodies have myelin oligodendrocyte glycoprotein (MOG) antibodies. Although AQP4-mediated NMOSD and MOG-mediated NMOSD are clinically similar, they are distinct diseases, said Dr. Pawate. Pathology primarily affects myelin, not astrocytes, in MOG-positive NMOSD. Patients with MOG-positive NMOSD also tend not to have relapses, and the disorder has a better prognosis, compared with AQP4-positive NMOSD.
Between 15% and 30% of patients with NMOSD have oligoclonal bands, and 20% have an elevated IgG index. Unlike in MS, however, these findings tend to be transient. In addition, as much as 30% of patients with NMOSD may have other comorbid autoimmune disorders. A review of the literature indicated that 22 autoimmune conditions, including myasthenia gravis, ulcerative colitis, hypothyroidism, and thrombocytopenia, have been observed in patients with NMOSD. “We think that this indicates a heightened autoimmune response in general in those patients,” said Dr. Pawate.
Treatment of NMOSD
Treatment of NMOSD is based on the principle that relapses, which can be severe, result in disability. The disease does not progress between relapses, unlike MS. Therefore, the consensus is that relapses should be treated promptly and aggressively. Maintenance immunosuppression may prevent future relapses, and other symptoms can be managed as needed. “I have had a patient for 10 years now who, after the first attack, has not had any more attacks and is living fairly normally,” said Dr. Pawate.
Evidence supports plasma exchange as a standard treatment for relapses in NMOSD. It requires five to seven sessions and 1.5 volumes. This treatment removes antibodies and other soluble disease mediators, such as complement. Bonnan and Cabre found that administering plasma exchange early in the relapse can mitigate astrocyte dysfunction and prevent neuronal death.
In a 2012 study, patients with optic neuritis were treated with IV corticosteroids or IV corticosteroids plus plasma exchange. Approximately 75% of patients treated with plasma exchange had a final visual acuity better than 20/40, compared with 39% of patients who received steroids alone. About 13% of patients treated with plasma exchange had a final visual acuity worse than 20/200, compared with 56% of patients who received steroids alone.
In 2017, Bonnan et al found that short delay to plasma exchange is the strongest predictor of outcome in severe attacks of NMOSD. The rate of good recovery was approximately 80% when plasma exchange was performed within a day or so of relapse onset. Plasma exchange also was effective when administered at a week after onset. The therapeutic window closes at approximately three weeks after onset, said Dr. Pawate.
Neurologists should begin maintenance immunosuppression immediately, said Dr. Pawate. Rituximab has the best evidential support for this indication, but the drug can be expensive, and insurance reimbursement is not easy to obtain. Only one formal publication has examined mycophenolate, but neurologists have a lot of clinical experience with this treatment. It takes three to four months before mycophenolate achieves its full efficacy, so bridge therapy is required. Mealy et al found that with optimal dosing, rituximab reduces patients’ relapse rate by 94%, mycophenolate reduces it by 90%, and azathioprine reduces it by 72%.
In one case series, tocilizumab, a monoclonal antibody targeting IL-6, was effective in patients who had not responded to rituximab. Eculizumab, a monoclonal antibody targeting the complement factor C5a, may be another option, based on recent reports. Maintenance immunosuppression should continue for at least five years, and indefinitely for patients with AQP4 antibodies, said Dr. Pawate.
If it is not clear whether the diagnosis is NMOSD or MS, a neurologist should treat the patient for NMOSD, said Dr. Pawate. Mycophenolate and rituximab, the two most commonly used NMOSD treatments, are effective against MS as well, but several treatments for MS, such as natalizumab, fingolimod, and interferon beta, may exacerbate NMOSD.
A clinical evaluation is the best way to monitor the treatment’s effect, said Dr. Pawate. “Make sure they are not having any new symptoms, new vision complaints, new motor weakness, or sensory complaints. MRI is of limited value in treatment monitoring…. Basically, nothing substitutes for talking to the patient and performing an examination.”
—Erik Greb
Suggested Reading
Bonnan M, Cabre P. Plasma exchange in severe attacks of neuromyelitis optica. Mult Scler Int. 2012; 2012:787630.
Bonnan M, Valentino R, Debeugny S, et al. Short delay to initiate plasma exchange is the strongest predictor of outcome in severe attacks of NMO spectrum disorders. J Neurol Neurosurg Psychiatry. 2018;89(4):346-351.
Hyun JW, Jeong IH, Joung A, et al. Evaluation of the 2015 diagnostic criteria for neuromyelitis optica spectrum disorder. Neurology. 2016;86(19):1772-1779.
Iyer A, Elsone L, Appleton R, Jacob A. A review of the current literature and a guide to the early diagnosis of autoimmune disorders associated with neuromyelitis optica. Autoimmunity. 2014;47(3):154-161.
Lennon VA, Wingerchuk DM, Kryzer TJ, et al. A serum-autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis. Lancet. 2004;364(9451):2106-2112.
Mealy MA, Wingerchuk DM, Palace J, et al. Comparison of relapse and treatment failure rates among patients with neuromyelitis optica: multicenter study of treatment efficacy. JAMA Neurol. 2014;71(3):324-330.
Merle H, Olindo S, Jeannin S, et al. Treatment of optic neuritis by plasma exchange (add-on) in neuromyelitis optica. Arch Ophthalmol. 2012;130(7):858-862.
Weinshenker BG, Wingerchuk DM. Neuromyelitis spectrum disorders. Mayo Clin Proc. 2017;92(4):663-679.
Research has improved understanding of the disorder’s pathology and indicated which treatments are most beneficial.
Research has improved understanding of the disorder’s pathology and indicated which treatments are most beneficial.
HILTON HEAD, SC—Neuromyelitis optica spectrum disorder (NMOSD) can result in severe disability, but early diagnosis and treatment increase the likelihood that a patient will regain his or her baseline function, according to an overview provided at the 41st Annual Contemporary Clinical Neurology Symposium. Increased understanding of NMOSD has led to new diagnostic criteria, and emerging data are clarifying the question of effective treatments.
NMOSD As a Distinct Disorder
NMOSD originally was recognized as an inflammatory disorder of the CNS that causes transverse myelitis and optic neuritis, said Siddharama Pawate, MD, Associate Professor of Neurology at Vanderbilt University Medical Center in Nashville. Although neurologists first considered NMOSD a variant of multiple sclerosis (MS), the former has several features that distinguish it from the latter. These features include exceptionally severe relapses, spinal cord lesions that span more than three vertebral segments, and CSF that reveals pleocytosis and high protein levels. In addition, some MS treatments such as interferons, fingolimod, and natalizumab usually exacerbate, rather than mitigate, NMOSD.
In 2004, researchers found that antibodies against aquaporin-4 (AQP4) were almost 100% specific for NMOSD. Astrocytes and ependymal cells, but not oligodendrocytes or neurons, express AQP4. When anti-AQP4 antibodies bind to the membrane of an astrocyte, they disrupt the blood–brain barrier and eventually cause the astrocyte to die. The death of astrocytes promotes secondary damage of oligodendrocytes and neurons. Because of these processes, swelling in the spinal cord and the optic nerve are prominent features of NMOSD on MRI, said Dr. Pawate. The swelling, in turn, can lead to vascular compromise and necrosis, thus
Clinical Presentations of NMOSD
Approximately 75% of patients with NMOSD present with optic neuritis. The next most common clinical presentation is transverse myelitis, which may include paraparesis or quadriparesis, loss of sensation, and bladder or bowel dysfunction. About 35% of patients present with transverse myelitis. Optic neuritis and transverse myelitis occur simultaneously in about 10% of patients who present with NMOSD. “Unlike the MS lesions that are mostly in the white matter, NMOSD lesions in the spinal cord involve gray matter and white matter,” said Dr. Pawate. Other clinical features specific to NMOSD include severe neuropathic pain, tonic spasms that last for as long as 90 seconds, and pruritus. The latter symptom responds well to gabapentin, said Dr. Pawate.
NMOSD entails more severe optic neuritis than that associated with MS. It can be bilateral and lead to complete loss of vision. Optic neuritis usually is longitudinally extensive in NMOSD. A lesion length of 17.6 mm suffices to distinguish NMOSD from MS, and a length of more than 35 mm is approximately 100% specific for the former disorder. Swelling can cause necrosis in the optic nerve and result in poor recovery of vision. Furthermore, homonymous hemianopsia can happen in NMOSD due to damage to the optic tracts, but is rare in MS.
The clinical presentation of NMOSD also may include area postrema syndrome, which entails intractable nausea and vomiting. Patients may have cerebral or cerebellar lesions, symptomatic narcolepsy, or endocrine dysfunction (eg, syndrome of inappropriate antidiuretic hormone secretion).
The 2015 Diagnostic Criteria
Deepening understanding of NMOSD led to the development of new diagnostic criteria in 2015. The criteria identify optic neuritis, acute myelitis, area postrema syndrome, acute brainstem syndrome, symptomatic narcolepsy or acute diencephalic syndrome with MRI lesions typical of NMOSD, and symptomatic cerebral syndrome with MRI lesions typical of NMOSD as the six core clinical characteristics. If the patient tests positive for AQP4 antibodies and has one core clinical characteristic, a diagnosis of NMOSD is appropriate. If the patient tests negative for AQP4 antibodies, he or she must have two or more core clinical characteristics (at least one of which should be optic neuritis, acute myelitis, or area postrema syndrome) that are disseminated in space for a diagnosis of NMOSD to be appropriate. In both cases, alternative diagnoses also must be excluded.
Some patients who test negative for AQP4 antibodies have myelin oligodendrocyte glycoprotein (MOG) antibodies. Although AQP4-mediated NMOSD and MOG-mediated NMOSD are clinically similar, they are distinct diseases, said Dr. Pawate. Pathology primarily affects myelin, not astrocytes, in MOG-positive NMOSD. Patients with MOG-positive NMOSD also tend not to have relapses, and the disorder has a better prognosis, compared with AQP4-positive NMOSD.
Between 15% and 30% of patients with NMOSD have oligoclonal bands, and 20% have an elevated IgG index. Unlike in MS, however, these findings tend to be transient. In addition, as much as 30% of patients with NMOSD may have other comorbid autoimmune disorders. A review of the literature indicated that 22 autoimmune conditions, including myasthenia gravis, ulcerative colitis, hypothyroidism, and thrombocytopenia, have been observed in patients with NMOSD. “We think that this indicates a heightened autoimmune response in general in those patients,” said Dr. Pawate.
Treatment of NMOSD
Treatment of NMOSD is based on the principle that relapses, which can be severe, result in disability. The disease does not progress between relapses, unlike MS. Therefore, the consensus is that relapses should be treated promptly and aggressively. Maintenance immunosuppression may prevent future relapses, and other symptoms can be managed as needed. “I have had a patient for 10 years now who, after the first attack, has not had any more attacks and is living fairly normally,” said Dr. Pawate.
Evidence supports plasma exchange as a standard treatment for relapses in NMOSD. It requires five to seven sessions and 1.5 volumes. This treatment removes antibodies and other soluble disease mediators, such as complement. Bonnan and Cabre found that administering plasma exchange early in the relapse can mitigate astrocyte dysfunction and prevent neuronal death.
In a 2012 study, patients with optic neuritis were treated with IV corticosteroids or IV corticosteroids plus plasma exchange. Approximately 75% of patients treated with plasma exchange had a final visual acuity better than 20/40, compared with 39% of patients who received steroids alone. About 13% of patients treated with plasma exchange had a final visual acuity worse than 20/200, compared with 56% of patients who received steroids alone.
In 2017, Bonnan et al found that short delay to plasma exchange is the strongest predictor of outcome in severe attacks of NMOSD. The rate of good recovery was approximately 80% when plasma exchange was performed within a day or so of relapse onset. Plasma exchange also was effective when administered at a week after onset. The therapeutic window closes at approximately three weeks after onset, said Dr. Pawate.
Neurologists should begin maintenance immunosuppression immediately, said Dr. Pawate. Rituximab has the best evidential support for this indication, but the drug can be expensive, and insurance reimbursement is not easy to obtain. Only one formal publication has examined mycophenolate, but neurologists have a lot of clinical experience with this treatment. It takes three to four months before mycophenolate achieves its full efficacy, so bridge therapy is required. Mealy et al found that with optimal dosing, rituximab reduces patients’ relapse rate by 94%, mycophenolate reduces it by 90%, and azathioprine reduces it by 72%.
In one case series, tocilizumab, a monoclonal antibody targeting IL-6, was effective in patients who had not responded to rituximab. Eculizumab, a monoclonal antibody targeting the complement factor C5a, may be another option, based on recent reports. Maintenance immunosuppression should continue for at least five years, and indefinitely for patients with AQP4 antibodies, said Dr. Pawate.
If it is not clear whether the diagnosis is NMOSD or MS, a neurologist should treat the patient for NMOSD, said Dr. Pawate. Mycophenolate and rituximab, the two most commonly used NMOSD treatments, are effective against MS as well, but several treatments for MS, such as natalizumab, fingolimod, and interferon beta, may exacerbate NMOSD.
A clinical evaluation is the best way to monitor the treatment’s effect, said Dr. Pawate. “Make sure they are not having any new symptoms, new vision complaints, new motor weakness, or sensory complaints. MRI is of limited value in treatment monitoring…. Basically, nothing substitutes for talking to the patient and performing an examination.”
—Erik Greb
Suggested Reading
Bonnan M, Cabre P. Plasma exchange in severe attacks of neuromyelitis optica. Mult Scler Int. 2012; 2012:787630.
Bonnan M, Valentino R, Debeugny S, et al. Short delay to initiate plasma exchange is the strongest predictor of outcome in severe attacks of NMO spectrum disorders. J Neurol Neurosurg Psychiatry. 2018;89(4):346-351.
Hyun JW, Jeong IH, Joung A, et al. Evaluation of the 2015 diagnostic criteria for neuromyelitis optica spectrum disorder. Neurology. 2016;86(19):1772-1779.
Iyer A, Elsone L, Appleton R, Jacob A. A review of the current literature and a guide to the early diagnosis of autoimmune disorders associated with neuromyelitis optica. Autoimmunity. 2014;47(3):154-161.
Lennon VA, Wingerchuk DM, Kryzer TJ, et al. A serum-autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis. Lancet. 2004;364(9451):2106-2112.
Mealy MA, Wingerchuk DM, Palace J, et al. Comparison of relapse and treatment failure rates among patients with neuromyelitis optica: multicenter study of treatment efficacy. JAMA Neurol. 2014;71(3):324-330.
Merle H, Olindo S, Jeannin S, et al. Treatment of optic neuritis by plasma exchange (add-on) in neuromyelitis optica. Arch Ophthalmol. 2012;130(7):858-862.
Weinshenker BG, Wingerchuk DM. Neuromyelitis spectrum disorders. Mayo Clin Proc. 2017;92(4):663-679.
HILTON HEAD, SC—Neuromyelitis optica spectrum disorder (NMOSD) can result in severe disability, but early diagnosis and treatment increase the likelihood that a patient will regain his or her baseline function, according to an overview provided at the 41st Annual Contemporary Clinical Neurology Symposium. Increased understanding of NMOSD has led to new diagnostic criteria, and emerging data are clarifying the question of effective treatments.
NMOSD As a Distinct Disorder
NMOSD originally was recognized as an inflammatory disorder of the CNS that causes transverse myelitis and optic neuritis, said Siddharama Pawate, MD, Associate Professor of Neurology at Vanderbilt University Medical Center in Nashville. Although neurologists first considered NMOSD a variant of multiple sclerosis (MS), the former has several features that distinguish it from the latter. These features include exceptionally severe relapses, spinal cord lesions that span more than three vertebral segments, and CSF that reveals pleocytosis and high protein levels. In addition, some MS treatments such as interferons, fingolimod, and natalizumab usually exacerbate, rather than mitigate, NMOSD.
In 2004, researchers found that antibodies against aquaporin-4 (AQP4) were almost 100% specific for NMOSD. Astrocytes and ependymal cells, but not oligodendrocytes or neurons, express AQP4. When anti-AQP4 antibodies bind to the membrane of an astrocyte, they disrupt the blood–brain barrier and eventually cause the astrocyte to die. The death of astrocytes promotes secondary damage of oligodendrocytes and neurons. Because of these processes, swelling in the spinal cord and the optic nerve are prominent features of NMOSD on MRI, said Dr. Pawate. The swelling, in turn, can lead to vascular compromise and necrosis, thus
Clinical Presentations of NMOSD
Approximately 75% of patients with NMOSD present with optic neuritis. The next most common clinical presentation is transverse myelitis, which may include paraparesis or quadriparesis, loss of sensation, and bladder or bowel dysfunction. About 35% of patients present with transverse myelitis. Optic neuritis and transverse myelitis occur simultaneously in about 10% of patients who present with NMOSD. “Unlike the MS lesions that are mostly in the white matter, NMOSD lesions in the spinal cord involve gray matter and white matter,” said Dr. Pawate. Other clinical features specific to NMOSD include severe neuropathic pain, tonic spasms that last for as long as 90 seconds, and pruritus. The latter symptom responds well to gabapentin, said Dr. Pawate.
NMOSD entails more severe optic neuritis than that associated with MS. It can be bilateral and lead to complete loss of vision. Optic neuritis usually is longitudinally extensive in NMOSD. A lesion length of 17.6 mm suffices to distinguish NMOSD from MS, and a length of more than 35 mm is approximately 100% specific for the former disorder. Swelling can cause necrosis in the optic nerve and result in poor recovery of vision. Furthermore, homonymous hemianopsia can happen in NMOSD due to damage to the optic tracts, but is rare in MS.
The clinical presentation of NMOSD also may include area postrema syndrome, which entails intractable nausea and vomiting. Patients may have cerebral or cerebellar lesions, symptomatic narcolepsy, or endocrine dysfunction (eg, syndrome of inappropriate antidiuretic hormone secretion).
The 2015 Diagnostic Criteria
Deepening understanding of NMOSD led to the development of new diagnostic criteria in 2015. The criteria identify optic neuritis, acute myelitis, area postrema syndrome, acute brainstem syndrome, symptomatic narcolepsy or acute diencephalic syndrome with MRI lesions typical of NMOSD, and symptomatic cerebral syndrome with MRI lesions typical of NMOSD as the six core clinical characteristics. If the patient tests positive for AQP4 antibodies and has one core clinical characteristic, a diagnosis of NMOSD is appropriate. If the patient tests negative for AQP4 antibodies, he or she must have two or more core clinical characteristics (at least one of which should be optic neuritis, acute myelitis, or area postrema syndrome) that are disseminated in space for a diagnosis of NMOSD to be appropriate. In both cases, alternative diagnoses also must be excluded.
Some patients who test negative for AQP4 antibodies have myelin oligodendrocyte glycoprotein (MOG) antibodies. Although AQP4-mediated NMOSD and MOG-mediated NMOSD are clinically similar, they are distinct diseases, said Dr. Pawate. Pathology primarily affects myelin, not astrocytes, in MOG-positive NMOSD. Patients with MOG-positive NMOSD also tend not to have relapses, and the disorder has a better prognosis, compared with AQP4-positive NMOSD.
Between 15% and 30% of patients with NMOSD have oligoclonal bands, and 20% have an elevated IgG index. Unlike in MS, however, these findings tend to be transient. In addition, as much as 30% of patients with NMOSD may have other comorbid autoimmune disorders. A review of the literature indicated that 22 autoimmune conditions, including myasthenia gravis, ulcerative colitis, hypothyroidism, and thrombocytopenia, have been observed in patients with NMOSD. “We think that this indicates a heightened autoimmune response in general in those patients,” said Dr. Pawate.
Treatment of NMOSD
Treatment of NMOSD is based on the principle that relapses, which can be severe, result in disability. The disease does not progress between relapses, unlike MS. Therefore, the consensus is that relapses should be treated promptly and aggressively. Maintenance immunosuppression may prevent future relapses, and other symptoms can be managed as needed. “I have had a patient for 10 years now who, after the first attack, has not had any more attacks and is living fairly normally,” said Dr. Pawate.
Evidence supports plasma exchange as a standard treatment for relapses in NMOSD. It requires five to seven sessions and 1.5 volumes. This treatment removes antibodies and other soluble disease mediators, such as complement. Bonnan and Cabre found that administering plasma exchange early in the relapse can mitigate astrocyte dysfunction and prevent neuronal death.
In a 2012 study, patients with optic neuritis were treated with IV corticosteroids or IV corticosteroids plus plasma exchange. Approximately 75% of patients treated with plasma exchange had a final visual acuity better than 20/40, compared with 39% of patients who received steroids alone. About 13% of patients treated with plasma exchange had a final visual acuity worse than 20/200, compared with 56% of patients who received steroids alone.
In 2017, Bonnan et al found that short delay to plasma exchange is the strongest predictor of outcome in severe attacks of NMOSD. The rate of good recovery was approximately 80% when plasma exchange was performed within a day or so of relapse onset. Plasma exchange also was effective when administered at a week after onset. The therapeutic window closes at approximately three weeks after onset, said Dr. Pawate.
Neurologists should begin maintenance immunosuppression immediately, said Dr. Pawate. Rituximab has the best evidential support for this indication, but the drug can be expensive, and insurance reimbursement is not easy to obtain. Only one formal publication has examined mycophenolate, but neurologists have a lot of clinical experience with this treatment. It takes three to four months before mycophenolate achieves its full efficacy, so bridge therapy is required. Mealy et al found that with optimal dosing, rituximab reduces patients’ relapse rate by 94%, mycophenolate reduces it by 90%, and azathioprine reduces it by 72%.
In one case series, tocilizumab, a monoclonal antibody targeting IL-6, was effective in patients who had not responded to rituximab. Eculizumab, a monoclonal antibody targeting the complement factor C5a, may be another option, based on recent reports. Maintenance immunosuppression should continue for at least five years, and indefinitely for patients with AQP4 antibodies, said Dr. Pawate.
If it is not clear whether the diagnosis is NMOSD or MS, a neurologist should treat the patient for NMOSD, said Dr. Pawate. Mycophenolate and rituximab, the two most commonly used NMOSD treatments, are effective against MS as well, but several treatments for MS, such as natalizumab, fingolimod, and interferon beta, may exacerbate NMOSD.
A clinical evaluation is the best way to monitor the treatment’s effect, said Dr. Pawate. “Make sure they are not having any new symptoms, new vision complaints, new motor weakness, or sensory complaints. MRI is of limited value in treatment monitoring…. Basically, nothing substitutes for talking to the patient and performing an examination.”
—Erik Greb
Suggested Reading
Bonnan M, Cabre P. Plasma exchange in severe attacks of neuromyelitis optica. Mult Scler Int. 2012; 2012:787630.
Bonnan M, Valentino R, Debeugny S, et al. Short delay to initiate plasma exchange is the strongest predictor of outcome in severe attacks of NMO spectrum disorders. J Neurol Neurosurg Psychiatry. 2018;89(4):346-351.
Hyun JW, Jeong IH, Joung A, et al. Evaluation of the 2015 diagnostic criteria for neuromyelitis optica spectrum disorder. Neurology. 2016;86(19):1772-1779.
Iyer A, Elsone L, Appleton R, Jacob A. A review of the current literature and a guide to the early diagnosis of autoimmune disorders associated with neuromyelitis optica. Autoimmunity. 2014;47(3):154-161.
Lennon VA, Wingerchuk DM, Kryzer TJ, et al. A serum-autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis. Lancet. 2004;364(9451):2106-2112.
Mealy MA, Wingerchuk DM, Palace J, et al. Comparison of relapse and treatment failure rates among patients with neuromyelitis optica: multicenter study of treatment efficacy. JAMA Neurol. 2014;71(3):324-330.
Merle H, Olindo S, Jeannin S, et al. Treatment of optic neuritis by plasma exchange (add-on) in neuromyelitis optica. Arch Ophthalmol. 2012;130(7):858-862.
Weinshenker BG, Wingerchuk DM. Neuromyelitis spectrum disorders. Mayo Clin Proc. 2017;92(4):663-679.
Neurofilaments: A Biomarker of Long-Term Outcome in MS?
Baseline measurement of CSF-NfL may add prognostic information and help identify patients who should start high-efficacy therapy as early as possible.
In patients with multiple sclerosis (MS), levels of light-chain neurofilament (NfL) in CSF at diagnosis seem to predict long-term clinical outcome and conversion from the relapsing-remitting phase of the disease to the secondary progressive phase, according to a study published in the September issue of Multiple Sclerosis Journal. “NfL is thought to reflect ongoing axonal degeneration, which dominates early in the disease phase, and our results support that increased early disease activity, as identified by increased levels of CSF-NfL, has a prognostic effect several years later,” said lead author Alok Bhan, MD, and colleagues. Dr. Bhan works in the Department of Neurology at Stavanger University Hospital in Norway.
Searching for Prognostic Markers
To test whether CSF-NfL levels in patients with MS could predict clinical outcome, Dr. Bhan and colleagues conducted standardized clinical assessments of patients with newly diagnosed MS at baseline and at five- and 10-year follow-up. Expanded Disability Status Scale (EDSS) progression between assessments was defined as an increase of 1 point or more for scores less than 6 and of 0.5 points or more for scores of 6 or greater. CSF obtained at baseline was analyzed for levels of NfL using enzyme-linked immunosorbent assay technology.
The study cohort included 44 patients, of whom 35 (80%) had relapsing-remitting MS, seven (16%) had secondary progressive MS, and two (4%) had primary progressive MS at baseline. Patients who progressed on EDSS tended to have higher median baseline CSF-NfL levels than patients who did not progress after five years (947 ng/L vs 246 ng/L, respectively) and those who did not progress after 10 years (708 ng/L vs 265 ng/L, respectively), although the latter difference was not statistically significant. Patients who converted from relapsing-remitting MS to secondary progressive MS at five years had a significantly higher median CSF level of NfL (2,122 ng/L), compared with those who did not convert (246 ng/L).
“We found a statistically significant correlation between NfL levels at baseline and EDSS progression and conversion from relapsing-remitting MS to secondary progressive MS at the five-year follow-up, but a weaker correlation at the 10-year follow-up,” the researchers said. “This [finding] may be due to the increasing number of patients on disease-modifying therapy throughout the study period, as only 16% received therapy at baseline, but 54% [did] at 10-year follow-up.”
The Predictive Value of NfL
“This is now another important report underscoring the predictive value of NfL levels for the evolution of future disability in MS, but the … study clearly suffers from the relatively low number of patients investigated,” said Michael Khalil, MD, PhD, in an accompanying editorial. Dr. Khalil is an Associate Professor of General Neurology at the Medical University of Graz in Austria. “Nevertheless, neurofilaments are currently the most promising markers to indicate neuro-axonal damage in MS and other neurologic diseases. The availability of a highly sensitive blood assay now facilitates its use for further research and in clinical practice.”
—Glenn S. Williams
Suggested Reading
Bhan A, Jacobsen C, Myhr KM, et al. Neurofilaments and 10-year follow-up in multiple sclerosis. Mult Scler. 2018; 24(10):1301-1307.
Khalil M. Are neurofilaments valuable biomarkers for long-term disease prognostication in MS? Mult Scler. 2018; 24(10):1270-1271.
Baseline measurement of CSF-NfL may add prognostic information and help identify patients who should start high-efficacy therapy as early as possible.
Baseline measurement of CSF-NfL may add prognostic information and help identify patients who should start high-efficacy therapy as early as possible.
In patients with multiple sclerosis (MS), levels of light-chain neurofilament (NfL) in CSF at diagnosis seem to predict long-term clinical outcome and conversion from the relapsing-remitting phase of the disease to the secondary progressive phase, according to a study published in the September issue of Multiple Sclerosis Journal. “NfL is thought to reflect ongoing axonal degeneration, which dominates early in the disease phase, and our results support that increased early disease activity, as identified by increased levels of CSF-NfL, has a prognostic effect several years later,” said lead author Alok Bhan, MD, and colleagues. Dr. Bhan works in the Department of Neurology at Stavanger University Hospital in Norway.
Searching for Prognostic Markers
To test whether CSF-NfL levels in patients with MS could predict clinical outcome, Dr. Bhan and colleagues conducted standardized clinical assessments of patients with newly diagnosed MS at baseline and at five- and 10-year follow-up. Expanded Disability Status Scale (EDSS) progression between assessments was defined as an increase of 1 point or more for scores less than 6 and of 0.5 points or more for scores of 6 or greater. CSF obtained at baseline was analyzed for levels of NfL using enzyme-linked immunosorbent assay technology.
The study cohort included 44 patients, of whom 35 (80%) had relapsing-remitting MS, seven (16%) had secondary progressive MS, and two (4%) had primary progressive MS at baseline. Patients who progressed on EDSS tended to have higher median baseline CSF-NfL levels than patients who did not progress after five years (947 ng/L vs 246 ng/L, respectively) and those who did not progress after 10 years (708 ng/L vs 265 ng/L, respectively), although the latter difference was not statistically significant. Patients who converted from relapsing-remitting MS to secondary progressive MS at five years had a significantly higher median CSF level of NfL (2,122 ng/L), compared with those who did not convert (246 ng/L).
“We found a statistically significant correlation between NfL levels at baseline and EDSS progression and conversion from relapsing-remitting MS to secondary progressive MS at the five-year follow-up, but a weaker correlation at the 10-year follow-up,” the researchers said. “This [finding] may be due to the increasing number of patients on disease-modifying therapy throughout the study period, as only 16% received therapy at baseline, but 54% [did] at 10-year follow-up.”
The Predictive Value of NfL
“This is now another important report underscoring the predictive value of NfL levels for the evolution of future disability in MS, but the … study clearly suffers from the relatively low number of patients investigated,” said Michael Khalil, MD, PhD, in an accompanying editorial. Dr. Khalil is an Associate Professor of General Neurology at the Medical University of Graz in Austria. “Nevertheless, neurofilaments are currently the most promising markers to indicate neuro-axonal damage in MS and other neurologic diseases. The availability of a highly sensitive blood assay now facilitates its use for further research and in clinical practice.”
—Glenn S. Williams
Suggested Reading
Bhan A, Jacobsen C, Myhr KM, et al. Neurofilaments and 10-year follow-up in multiple sclerosis. Mult Scler. 2018; 24(10):1301-1307.
Khalil M. Are neurofilaments valuable biomarkers for long-term disease prognostication in MS? Mult Scler. 2018; 24(10):1270-1271.
In patients with multiple sclerosis (MS), levels of light-chain neurofilament (NfL) in CSF at diagnosis seem to predict long-term clinical outcome and conversion from the relapsing-remitting phase of the disease to the secondary progressive phase, according to a study published in the September issue of Multiple Sclerosis Journal. “NfL is thought to reflect ongoing axonal degeneration, which dominates early in the disease phase, and our results support that increased early disease activity, as identified by increased levels of CSF-NfL, has a prognostic effect several years later,” said lead author Alok Bhan, MD, and colleagues. Dr. Bhan works in the Department of Neurology at Stavanger University Hospital in Norway.
Searching for Prognostic Markers
To test whether CSF-NfL levels in patients with MS could predict clinical outcome, Dr. Bhan and colleagues conducted standardized clinical assessments of patients with newly diagnosed MS at baseline and at five- and 10-year follow-up. Expanded Disability Status Scale (EDSS) progression between assessments was defined as an increase of 1 point or more for scores less than 6 and of 0.5 points or more for scores of 6 or greater. CSF obtained at baseline was analyzed for levels of NfL using enzyme-linked immunosorbent assay technology.
The study cohort included 44 patients, of whom 35 (80%) had relapsing-remitting MS, seven (16%) had secondary progressive MS, and two (4%) had primary progressive MS at baseline. Patients who progressed on EDSS tended to have higher median baseline CSF-NfL levels than patients who did not progress after five years (947 ng/L vs 246 ng/L, respectively) and those who did not progress after 10 years (708 ng/L vs 265 ng/L, respectively), although the latter difference was not statistically significant. Patients who converted from relapsing-remitting MS to secondary progressive MS at five years had a significantly higher median CSF level of NfL (2,122 ng/L), compared with those who did not convert (246 ng/L).
“We found a statistically significant correlation between NfL levels at baseline and EDSS progression and conversion from relapsing-remitting MS to secondary progressive MS at the five-year follow-up, but a weaker correlation at the 10-year follow-up,” the researchers said. “This [finding] may be due to the increasing number of patients on disease-modifying therapy throughout the study period, as only 16% received therapy at baseline, but 54% [did] at 10-year follow-up.”
The Predictive Value of NfL
“This is now another important report underscoring the predictive value of NfL levels for the evolution of future disability in MS, but the … study clearly suffers from the relatively low number of patients investigated,” said Michael Khalil, MD, PhD, in an accompanying editorial. Dr. Khalil is an Associate Professor of General Neurology at the Medical University of Graz in Austria. “Nevertheless, neurofilaments are currently the most promising markers to indicate neuro-axonal damage in MS and other neurologic diseases. The availability of a highly sensitive blood assay now facilitates its use for further research and in clinical practice.”
—Glenn S. Williams
Suggested Reading
Bhan A, Jacobsen C, Myhr KM, et al. Neurofilaments and 10-year follow-up in multiple sclerosis. Mult Scler. 2018; 24(10):1301-1307.
Khalil M. Are neurofilaments valuable biomarkers for long-term disease prognostication in MS? Mult Scler. 2018; 24(10):1270-1271.
How Many Patients Have Benign MS?
Patients and physicians interpret the term differently, thus making its use in the clinical setting problematic.
An estimated 3% of patients with multiple sclerosis (MS) have a benign course of disease, according to findings from a population-based UK study published online ahead of print September 3 in Journal of Neurology, Neurosurgery & Psychiatry. The term “benign MS” remains problematic, however.
“The study of the individuals with extremely favorable outcomes may uncover insights about disease pathogenesis or repair. However, the insensitivity of Expanded Disability Status Scale [EDSS]–based definitions of benign MS and the discrepancy between patient and clinician perception of benign MS undermine use of the term ‘benign’ in the clinical setting,” said Emma Clare Tallantyre, BMBS, PhD, Clinical Senior Lecturer in Neurosciences at Cardiff University in the UK, and her colleagues.
The investigators found that of 1,049 patients with a disease duration of longer than 15 years, 200 had a recent EDSS score of less than 4.0. Of those patients, 60 were clinically assessed, and nine (15%) had benign MS, which was defined as an EDSS score less than 3.0 and lack of significant fatigue, mood disturbance, cognitive impairment, and disruption to employment in the absence of disease-modifying therapy at at least 15 years after symptom onset.
Extrapolating these data, the investigators estimated that 30 patients in the study population of 1,049 had benign MS, yielding a prevalence of 2.9%. Of the 60 patients who were clinically assessed, 39 thought they had benign MS, based on the following definition: “When referring to illness, ‘benign’ usually means a condition which has little or no harmful effects on a person. There are no complications, and there is a good outcome or prognosis.”
Patients who self-reported benign MS had significantly lower EDSS scores, fewer depressive symptoms, lower fatigue severity, and lower reported MS impact than did patients who did not report benign MS. “Self-reported benign MS status showed poor agreement with our composite definition of benign MS status and only fair agreement with EDSS-based definitions of benign MS status,” said the investigators.
—Jeff Evans
Suggested Reading
Tallantyre EC, Major PC, Atherton MJ, et al. How common is truly benign MS in a UK population? J Neurol Neurosurg Psychiatry. 2018 Sep 3 [Epub ahead of print].
Patients and physicians interpret the term differently, thus making its use in the clinical setting problematic.
Patients and physicians interpret the term differently, thus making its use in the clinical setting problematic.
An estimated 3% of patients with multiple sclerosis (MS) have a benign course of disease, according to findings from a population-based UK study published online ahead of print September 3 in Journal of Neurology, Neurosurgery & Psychiatry. The term “benign MS” remains problematic, however.
“The study of the individuals with extremely favorable outcomes may uncover insights about disease pathogenesis or repair. However, the insensitivity of Expanded Disability Status Scale [EDSS]–based definitions of benign MS and the discrepancy between patient and clinician perception of benign MS undermine use of the term ‘benign’ in the clinical setting,” said Emma Clare Tallantyre, BMBS, PhD, Clinical Senior Lecturer in Neurosciences at Cardiff University in the UK, and her colleagues.
The investigators found that of 1,049 patients with a disease duration of longer than 15 years, 200 had a recent EDSS score of less than 4.0. Of those patients, 60 were clinically assessed, and nine (15%) had benign MS, which was defined as an EDSS score less than 3.0 and lack of significant fatigue, mood disturbance, cognitive impairment, and disruption to employment in the absence of disease-modifying therapy at at least 15 years after symptom onset.
Extrapolating these data, the investigators estimated that 30 patients in the study population of 1,049 had benign MS, yielding a prevalence of 2.9%. Of the 60 patients who were clinically assessed, 39 thought they had benign MS, based on the following definition: “When referring to illness, ‘benign’ usually means a condition which has little or no harmful effects on a person. There are no complications, and there is a good outcome or prognosis.”
Patients who self-reported benign MS had significantly lower EDSS scores, fewer depressive symptoms, lower fatigue severity, and lower reported MS impact than did patients who did not report benign MS. “Self-reported benign MS status showed poor agreement with our composite definition of benign MS status and only fair agreement with EDSS-based definitions of benign MS status,” said the investigators.
—Jeff Evans
Suggested Reading
Tallantyre EC, Major PC, Atherton MJ, et al. How common is truly benign MS in a UK population? J Neurol Neurosurg Psychiatry. 2018 Sep 3 [Epub ahead of print].
An estimated 3% of patients with multiple sclerosis (MS) have a benign course of disease, according to findings from a population-based UK study published online ahead of print September 3 in Journal of Neurology, Neurosurgery & Psychiatry. The term “benign MS” remains problematic, however.
“The study of the individuals with extremely favorable outcomes may uncover insights about disease pathogenesis or repair. However, the insensitivity of Expanded Disability Status Scale [EDSS]–based definitions of benign MS and the discrepancy between patient and clinician perception of benign MS undermine use of the term ‘benign’ in the clinical setting,” said Emma Clare Tallantyre, BMBS, PhD, Clinical Senior Lecturer in Neurosciences at Cardiff University in the UK, and her colleagues.
The investigators found that of 1,049 patients with a disease duration of longer than 15 years, 200 had a recent EDSS score of less than 4.0. Of those patients, 60 were clinically assessed, and nine (15%) had benign MS, which was defined as an EDSS score less than 3.0 and lack of significant fatigue, mood disturbance, cognitive impairment, and disruption to employment in the absence of disease-modifying therapy at at least 15 years after symptom onset.
Extrapolating these data, the investigators estimated that 30 patients in the study population of 1,049 had benign MS, yielding a prevalence of 2.9%. Of the 60 patients who were clinically assessed, 39 thought they had benign MS, based on the following definition: “When referring to illness, ‘benign’ usually means a condition which has little or no harmful effects on a person. There are no complications, and there is a good outcome or prognosis.”
Patients who self-reported benign MS had significantly lower EDSS scores, fewer depressive symptoms, lower fatigue severity, and lower reported MS impact than did patients who did not report benign MS. “Self-reported benign MS status showed poor agreement with our composite definition of benign MS status and only fair agreement with EDSS-based definitions of benign MS status,” said the investigators.
—Jeff Evans
Suggested Reading
Tallantyre EC, Major PC, Atherton MJ, et al. How common is truly benign MS in a UK population? J Neurol Neurosurg Psychiatry. 2018 Sep 3 [Epub ahead of print].
Pregnancy registries are a valuable resource
Pregnancy registries are valuable sources of information. For many drugs, they are the primary source of the human pregnancy experience. However, although most of the registries use the word “pregnancy,” it is important to note that many also enroll women who took the target drug shortly before conception.
The strengths of these registries are their prospective nature (enrolled before the outcome is known) and enrollment over a wide geographical area. Typically, two types of pregnancy outcomes are obtained: those with birth defects and those without known birth defects (classified as live births, fetal deaths, and spontaneous abortions). Registries can identify early signals of teratogenicity, but they have several limitations: selection bias that results from voluntary reporting; target populations that are not representative; lost-to-follow-up pregnancies that may have had different outcomes than those with documented outcomes; elective terminations and fetal deaths without birth defects and spontaneous abortions, all of which may lack details; the lack of control groups (with some exceptions); and the publication of results that may be delayed or not be in a peer-reviewed journal. Because the total number of exposed pregnancies is unknown, the data cannot be used to calculate prevalences, but they can be used to estimate the proportion of birth defects. Some registries also collect data on retrospective reports (reported after outcome is known). Such reports are less representative of the target population because they can be biased toward the reporting of more unusual and severe outcomes. But they may be helpful in detecting unusual patterns of birth defects.
For the following drugs, web addresses can be obtained from the Food and Drug Administration website, List of Pregnancy Exposure Registries.
MotherToBaby
A large registry, the MotherToBaby Organization of Teratology Information Specialists (OTIS) (877-311-8972), involves patients in several different categories and the effects of the drugs on the embryo-fetus: autoimmune diseases (ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, psoriasis, Crohn’s disease, and multiple sclerosis); asthma at less than 20 weeks’ gestation; vaccines; and heterozygous or homozygous familial hypercholesterolemia.
For the autoimmune diseases, the drugs and trade names are abatacept (Orencia), adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), infliximab (Remicade), leflunomide (Arava), otezla (Apremilast), teriflunomide (Aubagio), tocilizumab (Actemra), tofacitinib (Xeljanz), and ustekinumab (Stelara).
For the asthma group, the drug being investigated is mepolizumab (Nucala).
Two vaccines – for tetanus, diphtheria, and pertussis (Tdap) and meningococcal disease caused by Neisseria meningitidis serogroups A, C, Y and W-135 (Menveo) – are being studied.
The last category is heterozygous or homozygous familial hypercholesterolemia. The two agents in this category are alirocumab (Praluent) and evolocumab (Repatha).
Other registries
Breast cancer
The Mother Pregnancy Registry, INC Research (800-690-6720), is enrolling breast cancer patients who have been treated during pregnancy with ado-trastuzumab emtansine (Kadcyla), pertuzumab (Perjeta), or trastuzumab (Herceptin).
Epilepsy
The Antiepileptic Drug Pregnancy registry (888-233-2334) is studying eslicarbazepine (Aptiom) and pregabalin (Lyrica).
Fabry disease
The Fabry Registry, Genzyme Corp (617-591-5500) is studying the use in pregnancy of agalsidase beta (Fabrazyme) for Fabry disease.
Fibromyalgia
The Savella Pregnancy Registry (877-643-3010) is looking for patients with fibromyalgia who are being treated with milnacipran (Savella).
Hepatitis B
The Ribavirin Pregnancy Registry, INC Research (800-593-2214) is looking for subjects with hepatitis C who have been treated with ribavirin (Copegus).
Hypercholesterolemia
Lomitapide (Juxtapid) is being studied by the Global Lomitapide Pregnancy Exposure Registry managed by Aegerion (877-902-4099). The drug is used for homozygous familial hypercholesterolemia.
Mucopolysaccharidosis
The Mucopolysaccharidosis I (MPS I) registry, Genzyme (617-591-5500) is studying the use of laronidase (Aldurazyme) for Hurler syndrome, Scheie syndrome, and Hurler-Scheie syndrome.
The use of galsulfase (Naglazyme) for Maroteaux-Lamy syndrome during pregnancy is under study by the Mucopolysaccharidosis VI (MPS VI), clinical surveillance program (BioMarin Pharmaceutical) (415-506-6849 or 415-506-6703).
Multiple sclerosis
Novartis is conducting the Gilenya Pregnancy Registry (877-598-7237) for patients with multiple sclerosis who are taking fingolimod (Gilenya).
Alemtuzumab (Lemtrada), also indicated for multiple sclerosis, is the target agent for the LEMTRADA Pregnancy Exposure Registry (866-758-2990).
Narcolepsy and other sleep disorders
Armodafinil (Nuvigil), used for excessive sleepiness associated with narcolepsy and other sleep disorders, is being studied in the Nuvigil Pregnancy Registry (866-404-4106). A second drug with the same indication and telephone number, modafinil (Provigil), is in the Provigil Pregnancy Registry.
Osteoporosis
Amgen’s Pregnancy Surveillance Program (800-772-6436) is enrolling pregnant subjects with osteoporosis who are being treated with denosumab (Prolia).
Others
Two Merck pregnancy registries (800-986-8999) cover the following conditions: type 2 diabetes sitagliptin+metformin (Janumet) or sitagliptin (Januvia); and migraine headaches rizatriptan (Maxalt).
GlaxoSmithKline is conducting two registries: the Belimumab Pregnancy Registry for patients with systemic lupus erythematosus treated with belimumab (Benlysta) (877-681-6296); and Promacta Pregnancy Registry for women treated for thrombocytopenia with eltrombopag (Promacta) (888-825-5249).
Psychiatric Drugs
The National Pregnancy Registry for Atypical Antipsychotics (866-961-2388) is studying 10 drugs: aripiprazole (Abilify), asenapine (Saphris), clozapine (Clozaril), iloperidone (Fanapt), lurasidone (Latuda), olanzapine (Zyprexa), paliperidone (Invega), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon).
The National Pregnancy Registry for Antidepressants (844-405-6185) is studying amitriptyline (Elavil), amoxapine (Asendin), bupropion (Forfivo XL and Wellbutrin), citalopram (Celexa), clomipramine (Anafranil), desipramine (Norpramin), desvenlafaxine (Prisiq), doxepin (Sinequan), escitalopram (Lexapro), fluvoxamine (Luvox), fluoxetine (Prozac), imipramine (Tofranil), isocarboxazid (Marplan), levomilnacipran (Fetzima), maprotiline (Ludiomil), mirtazapine (Remeron), nefazodone (Serzone), nortriptyline (Pamelor), paroxetine (Paxil), phenelzine (Nardill), protriptyline (Vivactil), selegiline (Emsam), sertraline (Zoloft), tranylcypromine (Pamate), trazodone (Desyrel), trimipramine (Surmontil), venlafaxine (Effexor), and vilazodone (Viibryd).
The National Pregnancy Registry of Psychostimulants (866-961-2388) is studying amphetamine (Adderall), dextroamphetamine (Dexedrine and Focalin), lisdexamfetamine (Vyvanse), methylphenidate (Concerta, Daytrana, Desoxyn, Ritalin), and modafinil (Provigil).
The antidepressant duloxetine (Cymbalta) is being studied by the Cymbalta Pregnancy Registry (866-814-6975).
Transplant patients
Renal transplant patients exposed to mycophenolate (CellCept) can be enrolled in the Transplantation Pregnancy Registry International (877-955-6877) or the Mycophenolate Pregnancy Registry (800-617-8191). The Transplantation Pregnancy Registry International also is enrolling renal transplant patients exposed to belatacept (Nulojix).
Vaccines
A quadrivalent influenza vaccine (Afluria) is being studied by the Seqirus Influenza Vaccine Pregnancy Registry (855-358-8972). A second vaccine for meningococcal disease meningococcal disease caused by Neisseria meningitidis serogroups A, C, Y and W-135 (Menactra) is under study by the Menactra Vaccine Pregnancy Registry (800-822-2463). The Bexsero Pregnancy Registry (877-413-4759) is open to patients who have received the meningococcal group B vaccine (Bexsero). The Hepatitis B Vaccine [Recombinant] Adjuvanted Pregnancy Registry, also listed as HEPLISAV-B, is enrolling patients who have received that vaccine (844-443-7734); it is supported by the Dynavax Technologies Corporation.
Because the strength of a registry is based on numbers, health care professionals are encouraged to enroll potential subjects or have their patients call to enroll themselves.
Mr. Briggs is clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at obnews@mdedge.com.
Pregnancy registries are valuable sources of information. For many drugs, they are the primary source of the human pregnancy experience. However, although most of the registries use the word “pregnancy,” it is important to note that many also enroll women who took the target drug shortly before conception.
The strengths of these registries are their prospective nature (enrolled before the outcome is known) and enrollment over a wide geographical area. Typically, two types of pregnancy outcomes are obtained: those with birth defects and those without known birth defects (classified as live births, fetal deaths, and spontaneous abortions). Registries can identify early signals of teratogenicity, but they have several limitations: selection bias that results from voluntary reporting; target populations that are not representative; lost-to-follow-up pregnancies that may have had different outcomes than those with documented outcomes; elective terminations and fetal deaths without birth defects and spontaneous abortions, all of which may lack details; the lack of control groups (with some exceptions); and the publication of results that may be delayed or not be in a peer-reviewed journal. Because the total number of exposed pregnancies is unknown, the data cannot be used to calculate prevalences, but they can be used to estimate the proportion of birth defects. Some registries also collect data on retrospective reports (reported after outcome is known). Such reports are less representative of the target population because they can be biased toward the reporting of more unusual and severe outcomes. But they may be helpful in detecting unusual patterns of birth defects.
For the following drugs, web addresses can be obtained from the Food and Drug Administration website, List of Pregnancy Exposure Registries.
MotherToBaby
A large registry, the MotherToBaby Organization of Teratology Information Specialists (OTIS) (877-311-8972), involves patients in several different categories and the effects of the drugs on the embryo-fetus: autoimmune diseases (ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, psoriasis, Crohn’s disease, and multiple sclerosis); asthma at less than 20 weeks’ gestation; vaccines; and heterozygous or homozygous familial hypercholesterolemia.
For the autoimmune diseases, the drugs and trade names are abatacept (Orencia), adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), infliximab (Remicade), leflunomide (Arava), otezla (Apremilast), teriflunomide (Aubagio), tocilizumab (Actemra), tofacitinib (Xeljanz), and ustekinumab (Stelara).
For the asthma group, the drug being investigated is mepolizumab (Nucala).
Two vaccines – for tetanus, diphtheria, and pertussis (Tdap) and meningococcal disease caused by Neisseria meningitidis serogroups A, C, Y and W-135 (Menveo) – are being studied.
The last category is heterozygous or homozygous familial hypercholesterolemia. The two agents in this category are alirocumab (Praluent) and evolocumab (Repatha).
Other registries
Breast cancer
The Mother Pregnancy Registry, INC Research (800-690-6720), is enrolling breast cancer patients who have been treated during pregnancy with ado-trastuzumab emtansine (Kadcyla), pertuzumab (Perjeta), or trastuzumab (Herceptin).
Epilepsy
The Antiepileptic Drug Pregnancy registry (888-233-2334) is studying eslicarbazepine (Aptiom) and pregabalin (Lyrica).
Fabry disease
The Fabry Registry, Genzyme Corp (617-591-5500) is studying the use in pregnancy of agalsidase beta (Fabrazyme) for Fabry disease.
Fibromyalgia
The Savella Pregnancy Registry (877-643-3010) is looking for patients with fibromyalgia who are being treated with milnacipran (Savella).
Hepatitis B
The Ribavirin Pregnancy Registry, INC Research (800-593-2214) is looking for subjects with hepatitis C who have been treated with ribavirin (Copegus).
Hypercholesterolemia
Lomitapide (Juxtapid) is being studied by the Global Lomitapide Pregnancy Exposure Registry managed by Aegerion (877-902-4099). The drug is used for homozygous familial hypercholesterolemia.
Mucopolysaccharidosis
The Mucopolysaccharidosis I (MPS I) registry, Genzyme (617-591-5500) is studying the use of laronidase (Aldurazyme) for Hurler syndrome, Scheie syndrome, and Hurler-Scheie syndrome.
The use of galsulfase (Naglazyme) for Maroteaux-Lamy syndrome during pregnancy is under study by the Mucopolysaccharidosis VI (MPS VI), clinical surveillance program (BioMarin Pharmaceutical) (415-506-6849 or 415-506-6703).
Multiple sclerosis
Novartis is conducting the Gilenya Pregnancy Registry (877-598-7237) for patients with multiple sclerosis who are taking fingolimod (Gilenya).
Alemtuzumab (Lemtrada), also indicated for multiple sclerosis, is the target agent for the LEMTRADA Pregnancy Exposure Registry (866-758-2990).
Narcolepsy and other sleep disorders
Armodafinil (Nuvigil), used for excessive sleepiness associated with narcolepsy and other sleep disorders, is being studied in the Nuvigil Pregnancy Registry (866-404-4106). A second drug with the same indication and telephone number, modafinil (Provigil), is in the Provigil Pregnancy Registry.
Osteoporosis
Amgen’s Pregnancy Surveillance Program (800-772-6436) is enrolling pregnant subjects with osteoporosis who are being treated with denosumab (Prolia).
Others
Two Merck pregnancy registries (800-986-8999) cover the following conditions: type 2 diabetes sitagliptin+metformin (Janumet) or sitagliptin (Januvia); and migraine headaches rizatriptan (Maxalt).
GlaxoSmithKline is conducting two registries: the Belimumab Pregnancy Registry for patients with systemic lupus erythematosus treated with belimumab (Benlysta) (877-681-6296); and Promacta Pregnancy Registry for women treated for thrombocytopenia with eltrombopag (Promacta) (888-825-5249).
Psychiatric Drugs
The National Pregnancy Registry for Atypical Antipsychotics (866-961-2388) is studying 10 drugs: aripiprazole (Abilify), asenapine (Saphris), clozapine (Clozaril), iloperidone (Fanapt), lurasidone (Latuda), olanzapine (Zyprexa), paliperidone (Invega), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon).
The National Pregnancy Registry for Antidepressants (844-405-6185) is studying amitriptyline (Elavil), amoxapine (Asendin), bupropion (Forfivo XL and Wellbutrin), citalopram (Celexa), clomipramine (Anafranil), desipramine (Norpramin), desvenlafaxine (Prisiq), doxepin (Sinequan), escitalopram (Lexapro), fluvoxamine (Luvox), fluoxetine (Prozac), imipramine (Tofranil), isocarboxazid (Marplan), levomilnacipran (Fetzima), maprotiline (Ludiomil), mirtazapine (Remeron), nefazodone (Serzone), nortriptyline (Pamelor), paroxetine (Paxil), phenelzine (Nardill), protriptyline (Vivactil), selegiline (Emsam), sertraline (Zoloft), tranylcypromine (Pamate), trazodone (Desyrel), trimipramine (Surmontil), venlafaxine (Effexor), and vilazodone (Viibryd).
The National Pregnancy Registry of Psychostimulants (866-961-2388) is studying amphetamine (Adderall), dextroamphetamine (Dexedrine and Focalin), lisdexamfetamine (Vyvanse), methylphenidate (Concerta, Daytrana, Desoxyn, Ritalin), and modafinil (Provigil).
The antidepressant duloxetine (Cymbalta) is being studied by the Cymbalta Pregnancy Registry (866-814-6975).
Transplant patients
Renal transplant patients exposed to mycophenolate (CellCept) can be enrolled in the Transplantation Pregnancy Registry International (877-955-6877) or the Mycophenolate Pregnancy Registry (800-617-8191). The Transplantation Pregnancy Registry International also is enrolling renal transplant patients exposed to belatacept (Nulojix).
Vaccines
A quadrivalent influenza vaccine (Afluria) is being studied by the Seqirus Influenza Vaccine Pregnancy Registry (855-358-8972). A second vaccine for meningococcal disease meningococcal disease caused by Neisseria meningitidis serogroups A, C, Y and W-135 (Menactra) is under study by the Menactra Vaccine Pregnancy Registry (800-822-2463). The Bexsero Pregnancy Registry (877-413-4759) is open to patients who have received the meningococcal group B vaccine (Bexsero). The Hepatitis B Vaccine [Recombinant] Adjuvanted Pregnancy Registry, also listed as HEPLISAV-B, is enrolling patients who have received that vaccine (844-443-7734); it is supported by the Dynavax Technologies Corporation.
Because the strength of a registry is based on numbers, health care professionals are encouraged to enroll potential subjects or have their patients call to enroll themselves.
Mr. Briggs is clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at obnews@mdedge.com.
Pregnancy registries are valuable sources of information. For many drugs, they are the primary source of the human pregnancy experience. However, although most of the registries use the word “pregnancy,” it is important to note that many also enroll women who took the target drug shortly before conception.
The strengths of these registries are their prospective nature (enrolled before the outcome is known) and enrollment over a wide geographical area. Typically, two types of pregnancy outcomes are obtained: those with birth defects and those without known birth defects (classified as live births, fetal deaths, and spontaneous abortions). Registries can identify early signals of teratogenicity, but they have several limitations: selection bias that results from voluntary reporting; target populations that are not representative; lost-to-follow-up pregnancies that may have had different outcomes than those with documented outcomes; elective terminations and fetal deaths without birth defects and spontaneous abortions, all of which may lack details; the lack of control groups (with some exceptions); and the publication of results that may be delayed or not be in a peer-reviewed journal. Because the total number of exposed pregnancies is unknown, the data cannot be used to calculate prevalences, but they can be used to estimate the proportion of birth defects. Some registries also collect data on retrospective reports (reported after outcome is known). Such reports are less representative of the target population because they can be biased toward the reporting of more unusual and severe outcomes. But they may be helpful in detecting unusual patterns of birth defects.
For the following drugs, web addresses can be obtained from the Food and Drug Administration website, List of Pregnancy Exposure Registries.
MotherToBaby
A large registry, the MotherToBaby Organization of Teratology Information Specialists (OTIS) (877-311-8972), involves patients in several different categories and the effects of the drugs on the embryo-fetus: autoimmune diseases (ankylosing spondylitis, rheumatoid arthritis, psoriatic arthritis, ulcerative colitis, psoriasis, Crohn’s disease, and multiple sclerosis); asthma at less than 20 weeks’ gestation; vaccines; and heterozygous or homozygous familial hypercholesterolemia.
For the autoimmune diseases, the drugs and trade names are abatacept (Orencia), adalimumab (Humira), certolizumab pegol (Cimzia), etanercept (Enbrel), infliximab (Remicade), leflunomide (Arava), otezla (Apremilast), teriflunomide (Aubagio), tocilizumab (Actemra), tofacitinib (Xeljanz), and ustekinumab (Stelara).
For the asthma group, the drug being investigated is mepolizumab (Nucala).
Two vaccines – for tetanus, diphtheria, and pertussis (Tdap) and meningococcal disease caused by Neisseria meningitidis serogroups A, C, Y and W-135 (Menveo) – are being studied.
The last category is heterozygous or homozygous familial hypercholesterolemia. The two agents in this category are alirocumab (Praluent) and evolocumab (Repatha).
Other registries
Breast cancer
The Mother Pregnancy Registry, INC Research (800-690-6720), is enrolling breast cancer patients who have been treated during pregnancy with ado-trastuzumab emtansine (Kadcyla), pertuzumab (Perjeta), or trastuzumab (Herceptin).
Epilepsy
The Antiepileptic Drug Pregnancy registry (888-233-2334) is studying eslicarbazepine (Aptiom) and pregabalin (Lyrica).
Fabry disease
The Fabry Registry, Genzyme Corp (617-591-5500) is studying the use in pregnancy of agalsidase beta (Fabrazyme) for Fabry disease.
Fibromyalgia
The Savella Pregnancy Registry (877-643-3010) is looking for patients with fibromyalgia who are being treated with milnacipran (Savella).
Hepatitis B
The Ribavirin Pregnancy Registry, INC Research (800-593-2214) is looking for subjects with hepatitis C who have been treated with ribavirin (Copegus).
Hypercholesterolemia
Lomitapide (Juxtapid) is being studied by the Global Lomitapide Pregnancy Exposure Registry managed by Aegerion (877-902-4099). The drug is used for homozygous familial hypercholesterolemia.
Mucopolysaccharidosis
The Mucopolysaccharidosis I (MPS I) registry, Genzyme (617-591-5500) is studying the use of laronidase (Aldurazyme) for Hurler syndrome, Scheie syndrome, and Hurler-Scheie syndrome.
The use of galsulfase (Naglazyme) for Maroteaux-Lamy syndrome during pregnancy is under study by the Mucopolysaccharidosis VI (MPS VI), clinical surveillance program (BioMarin Pharmaceutical) (415-506-6849 or 415-506-6703).
Multiple sclerosis
Novartis is conducting the Gilenya Pregnancy Registry (877-598-7237) for patients with multiple sclerosis who are taking fingolimod (Gilenya).
Alemtuzumab (Lemtrada), also indicated for multiple sclerosis, is the target agent for the LEMTRADA Pregnancy Exposure Registry (866-758-2990).
Narcolepsy and other sleep disorders
Armodafinil (Nuvigil), used for excessive sleepiness associated with narcolepsy and other sleep disorders, is being studied in the Nuvigil Pregnancy Registry (866-404-4106). A second drug with the same indication and telephone number, modafinil (Provigil), is in the Provigil Pregnancy Registry.
Osteoporosis
Amgen’s Pregnancy Surveillance Program (800-772-6436) is enrolling pregnant subjects with osteoporosis who are being treated with denosumab (Prolia).
Others
Two Merck pregnancy registries (800-986-8999) cover the following conditions: type 2 diabetes sitagliptin+metformin (Janumet) or sitagliptin (Januvia); and migraine headaches rizatriptan (Maxalt).
GlaxoSmithKline is conducting two registries: the Belimumab Pregnancy Registry for patients with systemic lupus erythematosus treated with belimumab (Benlysta) (877-681-6296); and Promacta Pregnancy Registry for women treated for thrombocytopenia with eltrombopag (Promacta) (888-825-5249).
Psychiatric Drugs
The National Pregnancy Registry for Atypical Antipsychotics (866-961-2388) is studying 10 drugs: aripiprazole (Abilify), asenapine (Saphris), clozapine (Clozaril), iloperidone (Fanapt), lurasidone (Latuda), olanzapine (Zyprexa), paliperidone (Invega), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon).
The National Pregnancy Registry for Antidepressants (844-405-6185) is studying amitriptyline (Elavil), amoxapine (Asendin), bupropion (Forfivo XL and Wellbutrin), citalopram (Celexa), clomipramine (Anafranil), desipramine (Norpramin), desvenlafaxine (Prisiq), doxepin (Sinequan), escitalopram (Lexapro), fluvoxamine (Luvox), fluoxetine (Prozac), imipramine (Tofranil), isocarboxazid (Marplan), levomilnacipran (Fetzima), maprotiline (Ludiomil), mirtazapine (Remeron), nefazodone (Serzone), nortriptyline (Pamelor), paroxetine (Paxil), phenelzine (Nardill), protriptyline (Vivactil), selegiline (Emsam), sertraline (Zoloft), tranylcypromine (Pamate), trazodone (Desyrel), trimipramine (Surmontil), venlafaxine (Effexor), and vilazodone (Viibryd).
The National Pregnancy Registry of Psychostimulants (866-961-2388) is studying amphetamine (Adderall), dextroamphetamine (Dexedrine and Focalin), lisdexamfetamine (Vyvanse), methylphenidate (Concerta, Daytrana, Desoxyn, Ritalin), and modafinil (Provigil).
The antidepressant duloxetine (Cymbalta) is being studied by the Cymbalta Pregnancy Registry (866-814-6975).
Transplant patients
Renal transplant patients exposed to mycophenolate (CellCept) can be enrolled in the Transplantation Pregnancy Registry International (877-955-6877) or the Mycophenolate Pregnancy Registry (800-617-8191). The Transplantation Pregnancy Registry International also is enrolling renal transplant patients exposed to belatacept (Nulojix).
Vaccines
A quadrivalent influenza vaccine (Afluria) is being studied by the Seqirus Influenza Vaccine Pregnancy Registry (855-358-8972). A second vaccine for meningococcal disease meningococcal disease caused by Neisseria meningitidis serogroups A, C, Y and W-135 (Menactra) is under study by the Menactra Vaccine Pregnancy Registry (800-822-2463). The Bexsero Pregnancy Registry (877-413-4759) is open to patients who have received the meningococcal group B vaccine (Bexsero). The Hepatitis B Vaccine [Recombinant] Adjuvanted Pregnancy Registry, also listed as HEPLISAV-B, is enrolling patients who have received that vaccine (844-443-7734); it is supported by the Dynavax Technologies Corporation.
Because the strength of a registry is based on numbers, health care professionals are encouraged to enroll potential subjects or have their patients call to enroll themselves.
Mr. Briggs is clinical professor of pharmacy at the University of California, San Francisco, and adjunct professor of pharmacy at the University of Southern California, Los Angeles, as well as at Washington State University, Spokane. Mr. Briggs said he had no relevant financial disclosures. Email him at obnews@mdedge.com.
ICYMI: Fingolimod effective in pediatric relapsing multiple sclerosis
Fingolimod reduced the rate of relapse as well as the deposition of lesions on MRI better than interferon beta-1a did over 2 years in pediatric patients with relapsing multiple sclerosis, according to the results of the PARADIGMS trial, published online Sept. 12 in the New England Journal of Medicine (2018; 379:1017-27. doi: 10.1056/NEJMoa1800149). More serious adverse events were seen in fingolimod-treated patients.
We covered the story before it was published in the journal. Find our conference coverage at the links below.
Fingolimod reduced the rate of relapse as well as the deposition of lesions on MRI better than interferon beta-1a did over 2 years in pediatric patients with relapsing multiple sclerosis, according to the results of the PARADIGMS trial, published online Sept. 12 in the New England Journal of Medicine (2018; 379:1017-27. doi: 10.1056/NEJMoa1800149). More serious adverse events were seen in fingolimod-treated patients.
We covered the story before it was published in the journal. Find our conference coverage at the links below.
Fingolimod reduced the rate of relapse as well as the deposition of lesions on MRI better than interferon beta-1a did over 2 years in pediatric patients with relapsing multiple sclerosis, according to the results of the PARADIGMS trial, published online Sept. 12 in the New England Journal of Medicine (2018; 379:1017-27. doi: 10.1056/NEJMoa1800149). More serious adverse events were seen in fingolimod-treated patients.
We covered the story before it was published in the journal. Find our conference coverage at the links below.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Benign MS is real in small minority of patients
Nearly 3% of patients with multiple sclerosis (MS) are estimated to have a truly benign course of disease over at least 15 years without the use of disease-modifying therapy, based on findings from a U.K. population-based study that also showed how poorly benign disease tracks with disability measures and lacks agreement between patients and physicians.
“The study of the individuals with extremely favorable outcomes may uncover insights about disease pathogenesis or repair. However, the insensitivity of EDSS [Expanded Disability Status Scale]–based definitions of benign MS and the discrepancy between patient and clinician perception of benign MS undermine use of the term ‘benign’ in the clinical setting,” Emma Clare Tallantyre, MD, of Cardiff (Wales) University, and her colleagues wrote in the Journal of Neurology, Neurosurgery & Psychiatry.
Dr. Tallantyre and her colleagues found that, of 1,049 patients with disease duration longer than 15 years, 200 had a recent EDSS score of less than 4.0. Of those 200, 60 were clinically assessed and 9 (15%) were found to have truly benign MS, defined as having an EDSS less than 3.0 and having no significant fatigue, mood disturbance, cognitive impairment, or disruption to employment in the absence of disease-modifying therapy at least 15 years after symptom onset.
The investigators extrapolated these data to estimate that 30 patients in the study population of 1,049 had truly benign MS, for a prevalence of 2.9%. However, of the 60 patients who were clinically assessed, 39 thought they had benign MS based on the lay definition provided: “When referring to illness, ‘benign’ usually means a condition which has little or no harmful effects on a person. There are no complications and there is a good outcome or prognosis.”
Patients who self-reported benign MS had significantly lower EDSS scores, fewer depressive symptoms, lower fatigue severity, and lower reported MS impact than did patients who did not report benign MS. “Self-reported benign MS status showed poor agreement with our composite definition of benign MS status and only fair agreement with EDSS-based definitions of benign MS status,” the investigators wrote.
SOURCE: Tallantyre EC et al. J Neurol Neurosurg Psychiatry. 2018 Sep 3. doi: 10.1136/jnnp-2018-318802.
Nearly 3% of patients with multiple sclerosis (MS) are estimated to have a truly benign course of disease over at least 15 years without the use of disease-modifying therapy, based on findings from a U.K. population-based study that also showed how poorly benign disease tracks with disability measures and lacks agreement between patients and physicians.
“The study of the individuals with extremely favorable outcomes may uncover insights about disease pathogenesis or repair. However, the insensitivity of EDSS [Expanded Disability Status Scale]–based definitions of benign MS and the discrepancy between patient and clinician perception of benign MS undermine use of the term ‘benign’ in the clinical setting,” Emma Clare Tallantyre, MD, of Cardiff (Wales) University, and her colleagues wrote in the Journal of Neurology, Neurosurgery & Psychiatry.
Dr. Tallantyre and her colleagues found that, of 1,049 patients with disease duration longer than 15 years, 200 had a recent EDSS score of less than 4.0. Of those 200, 60 were clinically assessed and 9 (15%) were found to have truly benign MS, defined as having an EDSS less than 3.0 and having no significant fatigue, mood disturbance, cognitive impairment, or disruption to employment in the absence of disease-modifying therapy at least 15 years after symptom onset.
The investigators extrapolated these data to estimate that 30 patients in the study population of 1,049 had truly benign MS, for a prevalence of 2.9%. However, of the 60 patients who were clinically assessed, 39 thought they had benign MS based on the lay definition provided: “When referring to illness, ‘benign’ usually means a condition which has little or no harmful effects on a person. There are no complications and there is a good outcome or prognosis.”
Patients who self-reported benign MS had significantly lower EDSS scores, fewer depressive symptoms, lower fatigue severity, and lower reported MS impact than did patients who did not report benign MS. “Self-reported benign MS status showed poor agreement with our composite definition of benign MS status and only fair agreement with EDSS-based definitions of benign MS status,” the investigators wrote.
SOURCE: Tallantyre EC et al. J Neurol Neurosurg Psychiatry. 2018 Sep 3. doi: 10.1136/jnnp-2018-318802.
Nearly 3% of patients with multiple sclerosis (MS) are estimated to have a truly benign course of disease over at least 15 years without the use of disease-modifying therapy, based on findings from a U.K. population-based study that also showed how poorly benign disease tracks with disability measures and lacks agreement between patients and physicians.
“The study of the individuals with extremely favorable outcomes may uncover insights about disease pathogenesis or repair. However, the insensitivity of EDSS [Expanded Disability Status Scale]–based definitions of benign MS and the discrepancy between patient and clinician perception of benign MS undermine use of the term ‘benign’ in the clinical setting,” Emma Clare Tallantyre, MD, of Cardiff (Wales) University, and her colleagues wrote in the Journal of Neurology, Neurosurgery & Psychiatry.
Dr. Tallantyre and her colleagues found that, of 1,049 patients with disease duration longer than 15 years, 200 had a recent EDSS score of less than 4.0. Of those 200, 60 were clinically assessed and 9 (15%) were found to have truly benign MS, defined as having an EDSS less than 3.0 and having no significant fatigue, mood disturbance, cognitive impairment, or disruption to employment in the absence of disease-modifying therapy at least 15 years after symptom onset.
The investigators extrapolated these data to estimate that 30 patients in the study population of 1,049 had truly benign MS, for a prevalence of 2.9%. However, of the 60 patients who were clinically assessed, 39 thought they had benign MS based on the lay definition provided: “When referring to illness, ‘benign’ usually means a condition which has little or no harmful effects on a person. There are no complications and there is a good outcome or prognosis.”
Patients who self-reported benign MS had significantly lower EDSS scores, fewer depressive symptoms, lower fatigue severity, and lower reported MS impact than did patients who did not report benign MS. “Self-reported benign MS status showed poor agreement with our composite definition of benign MS status and only fair agreement with EDSS-based definitions of benign MS status,” the investigators wrote.
SOURCE: Tallantyre EC et al. J Neurol Neurosurg Psychiatry. 2018 Sep 3. doi: 10.1136/jnnp-2018-318802.
FROM THE JOURNAL OF NEUROLOGY, NEUROSURGERY & PSYCHIATRY
Serum Nf-L shows promise as biomarker for BMT response in MS
LOS ANGELES – Serum neurofilament light chain shows promise as a biomarker for disease severity and response to treatment with autologous bone marrow transplant in patients with multiple sclerosis, according to findings from an analysis of paired samples.
Serum neurofilament light chain (Nf-L) levels were found to be significantly elevated in both the serum and cerebrospinal fluid (CSF) of 23 patients with aggressive multiple sclerosis (MS), compared with samples from 5 controls with noninflammatory neurologic conditions such as chronic fatigue syndrome or migraine. The levels in the patients with MS were significantly reduced following autologous bone marrow transplant (BMT), Simon Thebault, MD, reported in a poster at the annual meeting of the American Academy of Neurology.
Nf-L has been shown to be a biomarker for neuronal damage and to have potential for denoting disease severity and treatment response in MS; for this analysis, samples from patients were collected at baseline and annually for 3 years after transplant. Samples from controls were obtained for comparison.
“Our objective, really, was [to determine if we could] detect a treatment response in neurofilament light chain, and secondly, did the degree of neurofilament light chain being high at baseline predict anything about subsequent disease outcome?” Dr. Thebault, a third-year resident at the University of Ottawa, reported in the poster.
Indeed, a treatment response was detected; baseline levels were high, and levels in both serum and CSF were down significantly (P = .05) at both 1 and 3 years following bone marrow transplant, and they stayed down. “In fact, they were so low, they were not significantly different from [the levels] in noninflammatory controls,” he said, noting that serum and CSF NfL levels were highly correlated (r = .833; P less than .001).
Study subjects were patients with aggressive MS, characterized by early disease onset, rapid progression, frequent relapses, and poor treatment responses. Such patients who have received autologous BMT represent an interesting group for examining treatment responses, he said.
At baseline, these patients presumably have a high burden of tissue injury, which would be representative of high levels of Nf-L; good, prospective data show these patients have no evidence of ongoing inflammatory disease following an intensive regimen that includes chemoablation and reinfusion of autologous stem cells, which is representative of a significant reduction of neurofilament levels, he explained.
Importantly, serum and CSF levels were correlated in this study, he said, noting that most prior work has involved CSF, but “the real clinical utility in neurofilament light chain is probably in the serum, because patients don’t like having lumbar punctures too often.”
With respect to the second question pertaining to disease outcomes, the study did show that patients with baseline Nf-L levels above the median for the group had worse T1 lesion volumes at baseline and after transplant (P = .0021 at 36 months), and also had worsening brain atrophy even after transplant (P = .0389 at 60 months).
The curves appeared to be diverging, suggesting that, in the absence of inflammatory disease activity, patients with high Nf-L levels at baseline continue to have ongoing atrophy at a differential rate, compared with those with low baseline levels, Dr. Thebault said.
Other findings included better Expanded Disability Status Scale outcomes after transplant in patients with lower baseline Nf-L, and a trend toward worsening outcomes among those with higher baseline Nf-L levels, although the study may have been underpowered for this. Additionally, lower baseline Nf-L predicted significantly lower T1 and T2 lesion volume, number of gadolinium-enhancing lesions, and a reduction in brain atrophy, whereas higher baseline Nf-L predicted the opposite, he noted, adding that N-acetylaspartate-to-creatinine ratios also tended to vary inversely with Nf-L levels.
The most important findings of the study are “the sustained reduction in Nf-L levels after BMT, and that higher baseline levels predicted worse MRI outcomes,” Dr. Thebault noted. “Together these data add to a growing body of evidence that suggests that serum Nf-L has a role in monitoring treatment responses and even a predictive value in determining disease severity.”
This study was supported by Quanterix, which provided Nf-L assay kits. Dr. Thebault reported having no disclosures.
SOURCE: Thebault S et al. Neurology. 2018 Apr;90(15 Suppl.):P5.036.
LOS ANGELES – Serum neurofilament light chain shows promise as a biomarker for disease severity and response to treatment with autologous bone marrow transplant in patients with multiple sclerosis, according to findings from an analysis of paired samples.
Serum neurofilament light chain (Nf-L) levels were found to be significantly elevated in both the serum and cerebrospinal fluid (CSF) of 23 patients with aggressive multiple sclerosis (MS), compared with samples from 5 controls with noninflammatory neurologic conditions such as chronic fatigue syndrome or migraine. The levels in the patients with MS were significantly reduced following autologous bone marrow transplant (BMT), Simon Thebault, MD, reported in a poster at the annual meeting of the American Academy of Neurology.
Nf-L has been shown to be a biomarker for neuronal damage and to have potential for denoting disease severity and treatment response in MS; for this analysis, samples from patients were collected at baseline and annually for 3 years after transplant. Samples from controls were obtained for comparison.
“Our objective, really, was [to determine if we could] detect a treatment response in neurofilament light chain, and secondly, did the degree of neurofilament light chain being high at baseline predict anything about subsequent disease outcome?” Dr. Thebault, a third-year resident at the University of Ottawa, reported in the poster.
Indeed, a treatment response was detected; baseline levels were high, and levels in both serum and CSF were down significantly (P = .05) at both 1 and 3 years following bone marrow transplant, and they stayed down. “In fact, they were so low, they were not significantly different from [the levels] in noninflammatory controls,” he said, noting that serum and CSF NfL levels were highly correlated (r = .833; P less than .001).
Study subjects were patients with aggressive MS, characterized by early disease onset, rapid progression, frequent relapses, and poor treatment responses. Such patients who have received autologous BMT represent an interesting group for examining treatment responses, he said.
At baseline, these patients presumably have a high burden of tissue injury, which would be representative of high levels of Nf-L; good, prospective data show these patients have no evidence of ongoing inflammatory disease following an intensive regimen that includes chemoablation and reinfusion of autologous stem cells, which is representative of a significant reduction of neurofilament levels, he explained.
Importantly, serum and CSF levels were correlated in this study, he said, noting that most prior work has involved CSF, but “the real clinical utility in neurofilament light chain is probably in the serum, because patients don’t like having lumbar punctures too often.”
With respect to the second question pertaining to disease outcomes, the study did show that patients with baseline Nf-L levels above the median for the group had worse T1 lesion volumes at baseline and after transplant (P = .0021 at 36 months), and also had worsening brain atrophy even after transplant (P = .0389 at 60 months).
The curves appeared to be diverging, suggesting that, in the absence of inflammatory disease activity, patients with high Nf-L levels at baseline continue to have ongoing atrophy at a differential rate, compared with those with low baseline levels, Dr. Thebault said.
Other findings included better Expanded Disability Status Scale outcomes after transplant in patients with lower baseline Nf-L, and a trend toward worsening outcomes among those with higher baseline Nf-L levels, although the study may have been underpowered for this. Additionally, lower baseline Nf-L predicted significantly lower T1 and T2 lesion volume, number of gadolinium-enhancing lesions, and a reduction in brain atrophy, whereas higher baseline Nf-L predicted the opposite, he noted, adding that N-acetylaspartate-to-creatinine ratios also tended to vary inversely with Nf-L levels.
The most important findings of the study are “the sustained reduction in Nf-L levels after BMT, and that higher baseline levels predicted worse MRI outcomes,” Dr. Thebault noted. “Together these data add to a growing body of evidence that suggests that serum Nf-L has a role in monitoring treatment responses and even a predictive value in determining disease severity.”
This study was supported by Quanterix, which provided Nf-L assay kits. Dr. Thebault reported having no disclosures.
SOURCE: Thebault S et al. Neurology. 2018 Apr;90(15 Suppl.):P5.036.
LOS ANGELES – Serum neurofilament light chain shows promise as a biomarker for disease severity and response to treatment with autologous bone marrow transplant in patients with multiple sclerosis, according to findings from an analysis of paired samples.
Serum neurofilament light chain (Nf-L) levels were found to be significantly elevated in both the serum and cerebrospinal fluid (CSF) of 23 patients with aggressive multiple sclerosis (MS), compared with samples from 5 controls with noninflammatory neurologic conditions such as chronic fatigue syndrome or migraine. The levels in the patients with MS were significantly reduced following autologous bone marrow transplant (BMT), Simon Thebault, MD, reported in a poster at the annual meeting of the American Academy of Neurology.
Nf-L has been shown to be a biomarker for neuronal damage and to have potential for denoting disease severity and treatment response in MS; for this analysis, samples from patients were collected at baseline and annually for 3 years after transplant. Samples from controls were obtained for comparison.
“Our objective, really, was [to determine if we could] detect a treatment response in neurofilament light chain, and secondly, did the degree of neurofilament light chain being high at baseline predict anything about subsequent disease outcome?” Dr. Thebault, a third-year resident at the University of Ottawa, reported in the poster.
Indeed, a treatment response was detected; baseline levels were high, and levels in both serum and CSF were down significantly (P = .05) at both 1 and 3 years following bone marrow transplant, and they stayed down. “In fact, they were so low, they were not significantly different from [the levels] in noninflammatory controls,” he said, noting that serum and CSF NfL levels were highly correlated (r = .833; P less than .001).
Study subjects were patients with aggressive MS, characterized by early disease onset, rapid progression, frequent relapses, and poor treatment responses. Such patients who have received autologous BMT represent an interesting group for examining treatment responses, he said.
At baseline, these patients presumably have a high burden of tissue injury, which would be representative of high levels of Nf-L; good, prospective data show these patients have no evidence of ongoing inflammatory disease following an intensive regimen that includes chemoablation and reinfusion of autologous stem cells, which is representative of a significant reduction of neurofilament levels, he explained.
Importantly, serum and CSF levels were correlated in this study, he said, noting that most prior work has involved CSF, but “the real clinical utility in neurofilament light chain is probably in the serum, because patients don’t like having lumbar punctures too often.”
With respect to the second question pertaining to disease outcomes, the study did show that patients with baseline Nf-L levels above the median for the group had worse T1 lesion volumes at baseline and after transplant (P = .0021 at 36 months), and also had worsening brain atrophy even after transplant (P = .0389 at 60 months).
The curves appeared to be diverging, suggesting that, in the absence of inflammatory disease activity, patients with high Nf-L levels at baseline continue to have ongoing atrophy at a differential rate, compared with those with low baseline levels, Dr. Thebault said.
Other findings included better Expanded Disability Status Scale outcomes after transplant in patients with lower baseline Nf-L, and a trend toward worsening outcomes among those with higher baseline Nf-L levels, although the study may have been underpowered for this. Additionally, lower baseline Nf-L predicted significantly lower T1 and T2 lesion volume, number of gadolinium-enhancing lesions, and a reduction in brain atrophy, whereas higher baseline Nf-L predicted the opposite, he noted, adding that N-acetylaspartate-to-creatinine ratios also tended to vary inversely with Nf-L levels.
The most important findings of the study are “the sustained reduction in Nf-L levels after BMT, and that higher baseline levels predicted worse MRI outcomes,” Dr. Thebault noted. “Together these data add to a growing body of evidence that suggests that serum Nf-L has a role in monitoring treatment responses and even a predictive value in determining disease severity.”
This study was supported by Quanterix, which provided Nf-L assay kits. Dr. Thebault reported having no disclosures.
SOURCE: Thebault S et al. Neurology. 2018 Apr;90(15 Suppl.):P5.036.
REPORTING FROM AAN 2018
Key clinical point:
Major finding: Serum and cerebrospinal fluid Nf-L levels declines significantly after bone marrow transplant (P less than .05) and did not differ from the levels in controls.
Study details: An analysis of paired samples from 23 patients with multiple sclerosis and 5 controls.
Disclosures: This study was supported by Quanterix, which provided Nf-L assay kits. Dr. Thebault reported having no disclosures.
Source: Thebault S et al. Neurology. 2018 Apr;90(15 Suppl.):P5.036.
New MS subtype shows absence of cerebral white matter demyelination
A new subtype of multiple sclerosis called myelocortical multiple sclerosis is characterized by demyelination only in the spinal cord and cerebral cortex and not in the cerebral white matter.
A paper published online Aug. 21 in Lancet Neurology presents the results of a study of the brains and spinal cords of 100 patients who died of multiple sclerosis.
Bruce D. Trapp, PhD, of the Lerner Research Institute at the Cleveland Clinic in Ohio, and his coauthors wrote that while the demyelination of cerebral white matter is a pathologic hallmark of multiple sclerosis, previous research has found only around half of cerebral T2-weighted hyperintense white matter lesions are demyelinated, and these lesions account for less than a third of variance in the rate of brain atrophy.
“In the absence of specific MRI metrics for demyelination, the relationship between cerebral white-matter demyelination and neurodegeneration remains speculative,” they wrote.
In this study, researchers scanned the brains with MRI before autopsy, then took centimeter-thick hemispheric slices to study the white-matter lesions. They identified 12 individuals as having what they describe as ‘myelocortical multiple sclerosis,’ characterized by the absence of areas of cerebral white-matter discoloration indicative of demyelinated lesions.
The authors then compared these individuals to 12 individuals with typical multiple sclerosis matched by age, sex, MRI protocol, multiple sclerosis disease subtype, disease duration, and Expanded Disability Status Scale.
They found that while individuals with myelocortical multiple sclerosis did not have demyelinated lesions in the cerebral white matter, they had similar areas of demyelinated lesions in the cerebral cortex to individuals with typical multiple sclerosis (median 4.45% vs. 9.74% respectively, P = .5512).
However, the individuals with myelocortical multiple sclerosis had a significantly smaller area of spinal cord demyelination (median 3.81% vs. 13.81%, P = .0083).
Individuals with myelocortical multiple sclerosis also had significantly lower mean cortical neuronal densities, compared with healthy control brains in layer III, layer V, and layer VI. But individuals with typical multiple sclerosis only had a lower cortical neuronal density in layer V when compared with controls.
Researchers also saw that in typical multiple sclerosis, neuronal density decreased as the area of brain white-matter demyelination increased. However, this negative linear correlation was not seen in myelocortical multiple sclerosis.
On MRI, researchers were still able to see abnormalities in the cerebral white matter in individuals with myelocortical multiple sclerosis, in T2-weighted, T1-weighted and magnetization transfer ratios (MTR) images.
They also found similar total T2-weighted and T1-weighted lesion volumes in individuals with myelocortical and with typical multiple sclerosis, although individuals with typical multiple sclerosis had significantly greater MTR lesion volumes.
“We propose that myelocortical multiple sclerosis is characterized by spinal cord demyelination, subpial cortical demyelination, and an absence of cerebral white-matter demyelination,” the authors wrote. “Our findings indicate that abnormal cerebral white-matter T2-T1-MTR regions of interest are not always demyelinated, and this pathological evidence suggests that cerebral white-matter demyelination and cortical neuronal degeneration can be independent events in myelocortical multiple sclerosis.”
The authors noted that their study may have been affected by selection bias, as all the patients in the study had died from complications of advanced multiple sclerosis. They suggested that it was therefore not appropriate to conclude that the prevalence of myelocortical multiple sclerosis seen in their sample would be similar across the multiple sclerosis population, nor were the findings likely to apply to people with earlier stage disease.
The study was funded by the U.S. National Institutes of Health and National Multiple Sclerosis Society. One author was an employee of Renovo Neural, and three authors were employees of Biogen. One author declared a pending patent related to automated lesion segmentation from MRI images, and four authors declared funding, fees, and non-financial support from pharmaceutical companies.
SOURCE: Trapp B et al. Lancet Neurol. 2018 Aug 21. doi: 10.1016/ S1474-4422(18)30245-X.
A new subtype of multiple sclerosis called myelocortical multiple sclerosis is characterized by demyelination only in the spinal cord and cerebral cortex and not in the cerebral white matter.
A paper published online Aug. 21 in Lancet Neurology presents the results of a study of the brains and spinal cords of 100 patients who died of multiple sclerosis.
Bruce D. Trapp, PhD, of the Lerner Research Institute at the Cleveland Clinic in Ohio, and his coauthors wrote that while the demyelination of cerebral white matter is a pathologic hallmark of multiple sclerosis, previous research has found only around half of cerebral T2-weighted hyperintense white matter lesions are demyelinated, and these lesions account for less than a third of variance in the rate of brain atrophy.
“In the absence of specific MRI metrics for demyelination, the relationship between cerebral white-matter demyelination and neurodegeneration remains speculative,” they wrote.
In this study, researchers scanned the brains with MRI before autopsy, then took centimeter-thick hemispheric slices to study the white-matter lesions. They identified 12 individuals as having what they describe as ‘myelocortical multiple sclerosis,’ characterized by the absence of areas of cerebral white-matter discoloration indicative of demyelinated lesions.
The authors then compared these individuals to 12 individuals with typical multiple sclerosis matched by age, sex, MRI protocol, multiple sclerosis disease subtype, disease duration, and Expanded Disability Status Scale.
They found that while individuals with myelocortical multiple sclerosis did not have demyelinated lesions in the cerebral white matter, they had similar areas of demyelinated lesions in the cerebral cortex to individuals with typical multiple sclerosis (median 4.45% vs. 9.74% respectively, P = .5512).
However, the individuals with myelocortical multiple sclerosis had a significantly smaller area of spinal cord demyelination (median 3.81% vs. 13.81%, P = .0083).
Individuals with myelocortical multiple sclerosis also had significantly lower mean cortical neuronal densities, compared with healthy control brains in layer III, layer V, and layer VI. But individuals with typical multiple sclerosis only had a lower cortical neuronal density in layer V when compared with controls.
Researchers also saw that in typical multiple sclerosis, neuronal density decreased as the area of brain white-matter demyelination increased. However, this negative linear correlation was not seen in myelocortical multiple sclerosis.
On MRI, researchers were still able to see abnormalities in the cerebral white matter in individuals with myelocortical multiple sclerosis, in T2-weighted, T1-weighted and magnetization transfer ratios (MTR) images.
They also found similar total T2-weighted and T1-weighted lesion volumes in individuals with myelocortical and with typical multiple sclerosis, although individuals with typical multiple sclerosis had significantly greater MTR lesion volumes.
“We propose that myelocortical multiple sclerosis is characterized by spinal cord demyelination, subpial cortical demyelination, and an absence of cerebral white-matter demyelination,” the authors wrote. “Our findings indicate that abnormal cerebral white-matter T2-T1-MTR regions of interest are not always demyelinated, and this pathological evidence suggests that cerebral white-matter demyelination and cortical neuronal degeneration can be independent events in myelocortical multiple sclerosis.”
The authors noted that their study may have been affected by selection bias, as all the patients in the study had died from complications of advanced multiple sclerosis. They suggested that it was therefore not appropriate to conclude that the prevalence of myelocortical multiple sclerosis seen in their sample would be similar across the multiple sclerosis population, nor were the findings likely to apply to people with earlier stage disease.
The study was funded by the U.S. National Institutes of Health and National Multiple Sclerosis Society. One author was an employee of Renovo Neural, and three authors were employees of Biogen. One author declared a pending patent related to automated lesion segmentation from MRI images, and four authors declared funding, fees, and non-financial support from pharmaceutical companies.
SOURCE: Trapp B et al. Lancet Neurol. 2018 Aug 21. doi: 10.1016/ S1474-4422(18)30245-X.
A new subtype of multiple sclerosis called myelocortical multiple sclerosis is characterized by demyelination only in the spinal cord and cerebral cortex and not in the cerebral white matter.
A paper published online Aug. 21 in Lancet Neurology presents the results of a study of the brains and spinal cords of 100 patients who died of multiple sclerosis.
Bruce D. Trapp, PhD, of the Lerner Research Institute at the Cleveland Clinic in Ohio, and his coauthors wrote that while the demyelination of cerebral white matter is a pathologic hallmark of multiple sclerosis, previous research has found only around half of cerebral T2-weighted hyperintense white matter lesions are demyelinated, and these lesions account for less than a third of variance in the rate of brain atrophy.
“In the absence of specific MRI metrics for demyelination, the relationship between cerebral white-matter demyelination and neurodegeneration remains speculative,” they wrote.
In this study, researchers scanned the brains with MRI before autopsy, then took centimeter-thick hemispheric slices to study the white-matter lesions. They identified 12 individuals as having what they describe as ‘myelocortical multiple sclerosis,’ characterized by the absence of areas of cerebral white-matter discoloration indicative of demyelinated lesions.
The authors then compared these individuals to 12 individuals with typical multiple sclerosis matched by age, sex, MRI protocol, multiple sclerosis disease subtype, disease duration, and Expanded Disability Status Scale.
They found that while individuals with myelocortical multiple sclerosis did not have demyelinated lesions in the cerebral white matter, they had similar areas of demyelinated lesions in the cerebral cortex to individuals with typical multiple sclerosis (median 4.45% vs. 9.74% respectively, P = .5512).
However, the individuals with myelocortical multiple sclerosis had a significantly smaller area of spinal cord demyelination (median 3.81% vs. 13.81%, P = .0083).
Individuals with myelocortical multiple sclerosis also had significantly lower mean cortical neuronal densities, compared with healthy control brains in layer III, layer V, and layer VI. But individuals with typical multiple sclerosis only had a lower cortical neuronal density in layer V when compared with controls.
Researchers also saw that in typical multiple sclerosis, neuronal density decreased as the area of brain white-matter demyelination increased. However, this negative linear correlation was not seen in myelocortical multiple sclerosis.
On MRI, researchers were still able to see abnormalities in the cerebral white matter in individuals with myelocortical multiple sclerosis, in T2-weighted, T1-weighted and magnetization transfer ratios (MTR) images.
They also found similar total T2-weighted and T1-weighted lesion volumes in individuals with myelocortical and with typical multiple sclerosis, although individuals with typical multiple sclerosis had significantly greater MTR lesion volumes.
“We propose that myelocortical multiple sclerosis is characterized by spinal cord demyelination, subpial cortical demyelination, and an absence of cerebral white-matter demyelination,” the authors wrote. “Our findings indicate that abnormal cerebral white-matter T2-T1-MTR regions of interest are not always demyelinated, and this pathological evidence suggests that cerebral white-matter demyelination and cortical neuronal degeneration can be independent events in myelocortical multiple sclerosis.”
The authors noted that their study may have been affected by selection bias, as all the patients in the study had died from complications of advanced multiple sclerosis. They suggested that it was therefore not appropriate to conclude that the prevalence of myelocortical multiple sclerosis seen in their sample would be similar across the multiple sclerosis population, nor were the findings likely to apply to people with earlier stage disease.
The study was funded by the U.S. National Institutes of Health and National Multiple Sclerosis Society. One author was an employee of Renovo Neural, and three authors were employees of Biogen. One author declared a pending patent related to automated lesion segmentation from MRI images, and four authors declared funding, fees, and non-financial support from pharmaceutical companies.
SOURCE: Trapp B et al. Lancet Neurol. 2018 Aug 21. doi: 10.1016/ S1474-4422(18)30245-X.
FROM LANCET NEUROLOGY
Key clinical point: Researchers have identified a new subtype of multiple sclerosis.
Major finding: Individuals with myelocortical multiple sclerosis show demyelination in the spinal cord and cortex only.
Study details: Post-mortem study of brains and spinal cords of 100 individuals with multiple sclerosis.
Disclosures: The study was funded by the U.S. National Institutes of Health and National Multiple Sclerosis Society. One author was an employee of Renovo Neural, three authors were employees of Biogen. One author declared a pending patent related to automated lesion segmentation from MRI images, and four authors declared funding, fees and non-financial support from pharmaceutical companies.
Source: Trapp B et al. Lancet Neurol. 2018 Aug 21. doi: 10.1016/ S1474-4422(18)30245-X.
New MS criteria may create more false positives
The revised McDonald criteria for multiple sclerosis (MS) has led to more diagnoses in patients with clinically isolated syndrome (CIS), but a new study of the criteria has suggested that they may lead to a number of false positive MS diagnoses among patients with a less severe disease state.
“In our data, specificity of the 2017 criteria was significantly lower than for the 2010 criteria,” Roos M. van der Vuurst de Vries, MD, from the department of neurology at Erasmus Medical Center in Rotterdam, the Netherlands, and her colleagues wrote in JAMA Neurology. “Earlier data showed that the previous McDonald criteria lead to a higher number of MS diagnoses in patients who will not have a second attack.”
Dr. van der Vuurst de Vries and her colleagues analyzed data from 229 patients with a CIS who underwent an MRI of the spinal cord to assess for dissemination in space (DIS); of these, 180 patients were scored for both DIS and dissemination in time (DIT) and had a “baseline MRI scan that included T1 images after gadolinium administration or scans that did not show any T2 hyperintense lesions.” Some patients also underwent a baseline lumbar puncture if clinically required.
Patients were assessed using both the 2010 and 2017 McDonald criteria for MS, and results were measured using sensitivity, specificity, positive predictive and negative predictive values, and accuracy at 1-year, 3-year, and 5-year follow-up. “The most important addition is that the new criteria allow MS diagnosis when the MRI scan meets criteria for DIS and unique oligoclonal bands (OCB) are present in [cerebrospinal fluid], even in absence of DIT on the MRI scan,” the researchers wrote. “The other major difference is that not only asymptomatic but also symptomatic lesions can be used to demonstrate DIS and DIT on MRI. Furthermore, cortical lesions can be used to demonstrate dissemination in space.”
The researchers found that 124 patients met 2010 DIS criteria (54%) and that 74 patients (60%) went on to develop clinically definite MS, while 149 patients (65%) met 2017 DIS criteria, and 89 patients (60%) went on to clinically definite MS. There were 46 patients (26%) who met 2010 DIT criteria, and 33 of those patients (72%) were diagnosed with clinically definite MS; 126 patients (70%) met 2017 DIT criteria, and 76 of those patients (60%) had clinically definite MS. The sensitivity for the 2010 criteria was 36% (95% confidence interval, 27%-47%)versus 68% for the 2017 criteria (95% CI, 57%-77%; P less than .001). However, specificity for the 2017 criteria was lower (61%; 95% CI, 50%-71%) when compared with the 2010 criteria (85%; 95% CI, 76%-92%; P less than .001). Researchers found more baseline MS diagnoses with the 2017 criteria than with the 2010 criteria, but they noted that 14 of 22 patients (64%) under the 2010 criteria and 26 of 48 patients (54%) under the 2017 criteria with MS had a second attack within 5 years.
The study was supported by the Dutch Multiple Sclerosis Research Foundation. One or more authors received compensation from Teva, Merck, Roche, Sanofi Genzyme, Biogen, and Novartis in the form of honoraria, for advisory board membership, as travel grants, or for participation in trials.
SOURCE: van der Vuurst de Vries RM, et al. JAMA Neurol. 2018 Aug 6. doi: 10.1001/jamaneurol.2018.2160.
The revised McDonald criteria for multiple sclerosis (MS) has led to more diagnoses in patients with clinically isolated syndrome (CIS), but a new study of the criteria has suggested that they may lead to a number of false positive MS diagnoses among patients with a less severe disease state.
“In our data, specificity of the 2017 criteria was significantly lower than for the 2010 criteria,” Roos M. van der Vuurst de Vries, MD, from the department of neurology at Erasmus Medical Center in Rotterdam, the Netherlands, and her colleagues wrote in JAMA Neurology. “Earlier data showed that the previous McDonald criteria lead to a higher number of MS diagnoses in patients who will not have a second attack.”
Dr. van der Vuurst de Vries and her colleagues analyzed data from 229 patients with a CIS who underwent an MRI of the spinal cord to assess for dissemination in space (DIS); of these, 180 patients were scored for both DIS and dissemination in time (DIT) and had a “baseline MRI scan that included T1 images after gadolinium administration or scans that did not show any T2 hyperintense lesions.” Some patients also underwent a baseline lumbar puncture if clinically required.
Patients were assessed using both the 2010 and 2017 McDonald criteria for MS, and results were measured using sensitivity, specificity, positive predictive and negative predictive values, and accuracy at 1-year, 3-year, and 5-year follow-up. “The most important addition is that the new criteria allow MS diagnosis when the MRI scan meets criteria for DIS and unique oligoclonal bands (OCB) are present in [cerebrospinal fluid], even in absence of DIT on the MRI scan,” the researchers wrote. “The other major difference is that not only asymptomatic but also symptomatic lesions can be used to demonstrate DIS and DIT on MRI. Furthermore, cortical lesions can be used to demonstrate dissemination in space.”
The researchers found that 124 patients met 2010 DIS criteria (54%) and that 74 patients (60%) went on to develop clinically definite MS, while 149 patients (65%) met 2017 DIS criteria, and 89 patients (60%) went on to clinically definite MS. There were 46 patients (26%) who met 2010 DIT criteria, and 33 of those patients (72%) were diagnosed with clinically definite MS; 126 patients (70%) met 2017 DIT criteria, and 76 of those patients (60%) had clinically definite MS. The sensitivity for the 2010 criteria was 36% (95% confidence interval, 27%-47%)versus 68% for the 2017 criteria (95% CI, 57%-77%; P less than .001). However, specificity for the 2017 criteria was lower (61%; 95% CI, 50%-71%) when compared with the 2010 criteria (85%; 95% CI, 76%-92%; P less than .001). Researchers found more baseline MS diagnoses with the 2017 criteria than with the 2010 criteria, but they noted that 14 of 22 patients (64%) under the 2010 criteria and 26 of 48 patients (54%) under the 2017 criteria with MS had a second attack within 5 years.
The study was supported by the Dutch Multiple Sclerosis Research Foundation. One or more authors received compensation from Teva, Merck, Roche, Sanofi Genzyme, Biogen, and Novartis in the form of honoraria, for advisory board membership, as travel grants, or for participation in trials.
SOURCE: van der Vuurst de Vries RM, et al. JAMA Neurol. 2018 Aug 6. doi: 10.1001/jamaneurol.2018.2160.
The revised McDonald criteria for multiple sclerosis (MS) has led to more diagnoses in patients with clinically isolated syndrome (CIS), but a new study of the criteria has suggested that they may lead to a number of false positive MS diagnoses among patients with a less severe disease state.
“In our data, specificity of the 2017 criteria was significantly lower than for the 2010 criteria,” Roos M. van der Vuurst de Vries, MD, from the department of neurology at Erasmus Medical Center in Rotterdam, the Netherlands, and her colleagues wrote in JAMA Neurology. “Earlier data showed that the previous McDonald criteria lead to a higher number of MS diagnoses in patients who will not have a second attack.”
Dr. van der Vuurst de Vries and her colleagues analyzed data from 229 patients with a CIS who underwent an MRI of the spinal cord to assess for dissemination in space (DIS); of these, 180 patients were scored for both DIS and dissemination in time (DIT) and had a “baseline MRI scan that included T1 images after gadolinium administration or scans that did not show any T2 hyperintense lesions.” Some patients also underwent a baseline lumbar puncture if clinically required.
Patients were assessed using both the 2010 and 2017 McDonald criteria for MS, and results were measured using sensitivity, specificity, positive predictive and negative predictive values, and accuracy at 1-year, 3-year, and 5-year follow-up. “The most important addition is that the new criteria allow MS diagnosis when the MRI scan meets criteria for DIS and unique oligoclonal bands (OCB) are present in [cerebrospinal fluid], even in absence of DIT on the MRI scan,” the researchers wrote. “The other major difference is that not only asymptomatic but also symptomatic lesions can be used to demonstrate DIS and DIT on MRI. Furthermore, cortical lesions can be used to demonstrate dissemination in space.”
The researchers found that 124 patients met 2010 DIS criteria (54%) and that 74 patients (60%) went on to develop clinically definite MS, while 149 patients (65%) met 2017 DIS criteria, and 89 patients (60%) went on to clinically definite MS. There were 46 patients (26%) who met 2010 DIT criteria, and 33 of those patients (72%) were diagnosed with clinically definite MS; 126 patients (70%) met 2017 DIT criteria, and 76 of those patients (60%) had clinically definite MS. The sensitivity for the 2010 criteria was 36% (95% confidence interval, 27%-47%)versus 68% for the 2017 criteria (95% CI, 57%-77%; P less than .001). However, specificity for the 2017 criteria was lower (61%; 95% CI, 50%-71%) when compared with the 2010 criteria (85%; 95% CI, 76%-92%; P less than .001). Researchers found more baseline MS diagnoses with the 2017 criteria than with the 2010 criteria, but they noted that 14 of 22 patients (64%) under the 2010 criteria and 26 of 48 patients (54%) under the 2017 criteria with MS had a second attack within 5 years.
The study was supported by the Dutch Multiple Sclerosis Research Foundation. One or more authors received compensation from Teva, Merck, Roche, Sanofi Genzyme, Biogen, and Novartis in the form of honoraria, for advisory board membership, as travel grants, or for participation in trials.
SOURCE: van der Vuurst de Vries RM, et al. JAMA Neurol. 2018 Aug 6. doi: 10.1001/jamaneurol.2018.2160.
FROM JAMA NEUROLOGY
Key clinical point: The 2017 McDonald criteria for MS may diagnose more patients with a clinically isolated syndrome, but a lower specificity may also capture more patients who do not have a second CIS event.
Major finding: The sensitivity for the 2017 criteria was greater at 68%, compared with 36% in the 2010 criteria; however, specificity was significantly lower in the 2017 criteria at 61%, compared with 85% in the 2010 criteria.
Data source: An original study of 229 patients from the Netherlands with CIS who underwent an MRI scan within 3 months of symptoms.
Disclosures: The study was supported by the Dutch Multiple Sclerosis Research Foundation. One or more authors received compensation from Teva, Merck, Roche, Sanofi Genzyme, Biogen, and Novartis in the form of honoraria, for advisory board membership, as travel grants, or for participation in trials.
Source: van der Vuurst de Vries RM et al. JAMA Neurol. 2018 Aug 6. doi: 10.1001/jamaneurol.2018.2160.
Aspirin May Be an Effective Pretreatment for Exercise in Patients With MS
Time to exhaustion was significantly greater after pretreatment with aspirin versus placebo.
LOS ANGELES—Aspirin may be an effective pretreatment for exercise in patients with multiple sclerosis (MS), according to a study described at the 70th Annual Meeting of the American Academy of Neurology.
“Exercise in MS we know to be beneficial on multiple levels,” said Victoria M. Leavitt, PhD, Assistant Professor of Neuropsychology at Columbia University Medical Center in New York. “In addition to physical benefits like gait, balance, and improved cardiovascular fitness, exercise is also associated with improved mood, reduced fatigue, and improved memory performance. The challenge, of course, is that exercise is only beneficial if people actually do it.”
Exercise-induced overheating, exhaustion, and symptom worsening (Uhtoff’s phenomenon) deter many patients with MS from exercise, and patients may have elevated resting body temperatures that are associated with worse fatigue.
To test whether aspirin pretreatment improves exercise performance in people with MS, Dr. Leavitt and colleagues conducted a randomized, placebo-controlled, crossover pilot study. The researchers studied aspirin because of its antipyretic effects and its efficacy in reducing fatigue in nonexercising patients with MS. The primary outcome was total time spent exercising. Change in exercise-induced body temperature was a secondary outcome.
In all, 12 patients participated in the study (nine females; mean age, 39.8; mean disease duration, 7.7 years; Expanded Disability Status Scale scores of 6.5 or less). Eight patients reported heat sensitivity during exercise.
Participants completed two maximal progressive ramped lower body cycle ergometer exercise tests one week apart after taking 650 mg of aspirin or placebo one hour before each test.
Patients exercised an average of 16.4 seconds longer after taking aspirin (9 minutes 28.6 seconds), versus placebo (9 minutes 12.2 seconds). In heat-sensitive patients, average body temperature increase after exercise with aspirin (0.41°F) was lower than the increase with placebo (0.88°F). This difference was not statistically significant.
Larger studies are needed, but the results are encouraging, Dr. Leavitt said. “The next thing we want to look at is how this translates to everyday exercise,” she said. “Does aspirin use in people with MS result in increased physical activity levels or increased adherence to exercise regimens?”
—Jake Remaly
Suggested Reading
Leavitt VM, Blanchard AR, Guo CY, et al. Aspirin is an effective pretreatment for exercise in multiple sclerosis: a double-blin
Wingerchuk DM, Benarroch EE, O’Brien PC, et al. A randomized controlled crossover trial of aspirin for fatigue in multiple sclerosis. Neurology. 2005;64(7):1267-1269.
Time to exhaustion was significantly greater after pretreatment with aspirin versus placebo.
Time to exhaustion was significantly greater after pretreatment with aspirin versus placebo.
LOS ANGELES—Aspirin may be an effective pretreatment for exercise in patients with multiple sclerosis (MS), according to a study described at the 70th Annual Meeting of the American Academy of Neurology.
“Exercise in MS we know to be beneficial on multiple levels,” said Victoria M. Leavitt, PhD, Assistant Professor of Neuropsychology at Columbia University Medical Center in New York. “In addition to physical benefits like gait, balance, and improved cardiovascular fitness, exercise is also associated with improved mood, reduced fatigue, and improved memory performance. The challenge, of course, is that exercise is only beneficial if people actually do it.”
Exercise-induced overheating, exhaustion, and symptom worsening (Uhtoff’s phenomenon) deter many patients with MS from exercise, and patients may have elevated resting body temperatures that are associated with worse fatigue.
To test whether aspirin pretreatment improves exercise performance in people with MS, Dr. Leavitt and colleagues conducted a randomized, placebo-controlled, crossover pilot study. The researchers studied aspirin because of its antipyretic effects and its efficacy in reducing fatigue in nonexercising patients with MS. The primary outcome was total time spent exercising. Change in exercise-induced body temperature was a secondary outcome.
In all, 12 patients participated in the study (nine females; mean age, 39.8; mean disease duration, 7.7 years; Expanded Disability Status Scale scores of 6.5 or less). Eight patients reported heat sensitivity during exercise.
Participants completed two maximal progressive ramped lower body cycle ergometer exercise tests one week apart after taking 650 mg of aspirin or placebo one hour before each test.
Patients exercised an average of 16.4 seconds longer after taking aspirin (9 minutes 28.6 seconds), versus placebo (9 minutes 12.2 seconds). In heat-sensitive patients, average body temperature increase after exercise with aspirin (0.41°F) was lower than the increase with placebo (0.88°F). This difference was not statistically significant.
Larger studies are needed, but the results are encouraging, Dr. Leavitt said. “The next thing we want to look at is how this translates to everyday exercise,” she said. “Does aspirin use in people with MS result in increased physical activity levels or increased adherence to exercise regimens?”
—Jake Remaly
Suggested Reading
Leavitt VM, Blanchard AR, Guo CY, et al. Aspirin is an effective pretreatment for exercise in multiple sclerosis: a double-blin
Wingerchuk DM, Benarroch EE, O’Brien PC, et al. A randomized controlled crossover trial of aspirin for fatigue in multiple sclerosis. Neurology. 2005;64(7):1267-1269.
LOS ANGELES—Aspirin may be an effective pretreatment for exercise in patients with multiple sclerosis (MS), according to a study described at the 70th Annual Meeting of the American Academy of Neurology.
“Exercise in MS we know to be beneficial on multiple levels,” said Victoria M. Leavitt, PhD, Assistant Professor of Neuropsychology at Columbia University Medical Center in New York. “In addition to physical benefits like gait, balance, and improved cardiovascular fitness, exercise is also associated with improved mood, reduced fatigue, and improved memory performance. The challenge, of course, is that exercise is only beneficial if people actually do it.”
Exercise-induced overheating, exhaustion, and symptom worsening (Uhtoff’s phenomenon) deter many patients with MS from exercise, and patients may have elevated resting body temperatures that are associated with worse fatigue.
To test whether aspirin pretreatment improves exercise performance in people with MS, Dr. Leavitt and colleagues conducted a randomized, placebo-controlled, crossover pilot study. The researchers studied aspirin because of its antipyretic effects and its efficacy in reducing fatigue in nonexercising patients with MS. The primary outcome was total time spent exercising. Change in exercise-induced body temperature was a secondary outcome.
In all, 12 patients participated in the study (nine females; mean age, 39.8; mean disease duration, 7.7 years; Expanded Disability Status Scale scores of 6.5 or less). Eight patients reported heat sensitivity during exercise.
Participants completed two maximal progressive ramped lower body cycle ergometer exercise tests one week apart after taking 650 mg of aspirin or placebo one hour before each test.
Patients exercised an average of 16.4 seconds longer after taking aspirin (9 minutes 28.6 seconds), versus placebo (9 minutes 12.2 seconds). In heat-sensitive patients, average body temperature increase after exercise with aspirin (0.41°F) was lower than the increase with placebo (0.88°F). This difference was not statistically significant.
Larger studies are needed, but the results are encouraging, Dr. Leavitt said. “The next thing we want to look at is how this translates to everyday exercise,” she said. “Does aspirin use in people with MS result in increased physical activity levels or increased adherence to exercise regimens?”
—Jake Remaly
Suggested Reading
Leavitt VM, Blanchard AR, Guo CY, et al. Aspirin is an effective pretreatment for exercise in multiple sclerosis: a double-blin
Wingerchuk DM, Benarroch EE, O’Brien PC, et al. A randomized controlled crossover trial of aspirin for fatigue in multiple sclerosis. Neurology. 2005;64(7):1267-1269.
