Background

Natalizumab and fingolimod are indicated in the EU for patients with rapidly evolving severe relapsing-remitting multiple sclerosis (RES RRMS; ≥2 relapses in 1 year and ≥1 gadolinium-enhancing lesions or increased T2 lesion numbers on MRI) or highly active RRMS. Patients with RRMS may also receive first-line therapies (interferon beta, glatiramer acetate, dimethyl fumarate, or teriflunomide; collectively BRACETD). Effectiveness comparisons of therapies in patients with RES RRMS are lacking.

Objectives

To compare the clinical effectiveness of natalizumab, fingolimod, and BRACETD in patients with RES RRMS in real-world settings.

Methods

Data from the MSBase registry as of August 2019 were used. Adults with RRMS, ≥2 relapses in the past 12 months, and available Expanded Disability Status Scale scores at baseline (BL) and on therapy were included. At index date, patients were treatment naive or had switched from BRACETD to natalizumab, fingolimod, or another BRACETD. Patients were propensity score matched 1:1:1 based on BL demographic and clinical variables. Annualized relapse rates (ARRs) were compared using a generalised estimating equation Poisson regression model. Other outcomes (time to first relapse, 6-month confirmed disability worsening [CDW], and 6-month confirmed disability improvement [CDI]) were analysed using Cox marginal regression models.

Results

Matched treatment groups included 721 triplets of patients with mean follow-up of approximately 3 years. In each group, 23.3–23.9% of patients were treatment naïve. ARR (95% CI) was lowest with natalizumab (0.18 [0.17–0.20]) followed by fingolimod (0.29 [0.26–0.31]) and BRACETD (0.39 [0.37–0.42]; P<0.001 for all comparisons); rate ratio (95% CI) vs BRACETD was 0.46 (0.42–0.53) for natalizumab and 0.72 (0.65–0.80) for fingolimod. Risk of first relapse was lower with natalizumab vs fingolimod (hazard ratio [HR] [95% CI], 0.63 [0.53–0.74]) or BRACETD (0.41 [0.36–0.48]; P<0.001 for both) and with fingolimod vs BRACETD (0.66 [0.57–0.76]; P<0.001). No differences in CDW were observed. CDI was more likely with natalizumab than with fingolimod (HR [95% CI], 1.25 [1.01–1.55]; P=0.047) or BRACETD (1.46 [1.16–1.85]; P=0.002). CDI was not significantly different between fingolimod and BRACETD (HR [95% CI], 1.17 [0.91–1.50]; P=0.209).

Conclusions

In this large cohort of patients with RES RRMS treated in real-world settings, natalizumab was more effective than fingolimod or BRACETD at reducing relapses. Natalizumab patients were also 25% and 46% more likely to exhibit CDI than fingolimod and BRACETD patients, respectively.

This study was supported by Biogen International (Zug, Switzerland).

Background

Some cohort studies have reported similar onset age and disability accrual in primary and secondary progressive MS (PPMS, SPMS); others have reported later onset and faster disability accrual in SPMS. Comparisons are complicated by differences in baseline disability and exposure to disease-modifying therapies (DMT), and by lack of a standardized definition of SPMS.

Objectives

We compared hazards of disability accrual in PPMS and SPMS patients from the MSBase cohort using multivariable Cox models, applying validated diagnostic criteria for SPMS (Lorscheider et al., Brain 2016).

Methods

Inclusion required adult-onset progressive MS; ≥ 3 recorded Expanded Disability Status Scale (EDSS) scores; and, for SPMS, initial records with EDSS ≤ 3 to allow objective identification of SPMS conversion. Phenotypes were subgrouped as active (PPMS-A, SPMS-A) if ≥ 1 progressive-phase relapse was recorded, and inactive (PPMS-N, SPMS-N) otherwise. Disability accrual was defined by sustained EDSS increases confirmed over ≥ 6 months. Hazard ratios (HR) for disability accrual were obtained using Andersen-Gill Cox models, adjusted for sex and time-varying age, disability, visit frequency, and proportion of time on DMT or immunosuppressive therapy. Sensitivity analyses were performed using (1) PPMS and SPMS diagnosed since 1995, and (2) physician-diagnosed SPMS. Cumulative probability of reaching EDSS ≥ 7 (wheelchair required) was assessed (Kaplan-Meier).

Results

5461 patients were included (1257 PPMS-N; 1308 PPMS-A; 1731 SPMS-N; 1165 SPMS-A). Age at progression onset was older in SPMS than PPMS (47.2 ± 10.2, vs. 41.5 ± 10.7 [mean ± SD]), and in the inactive subgroups of each phenotype. Hazard of disability accrual was decreased in SPMS relative to PPMS (HR 0.85; 95% CI 0.78–0.92); decreased by proportion of time on DMT (HR 0.99 per 10% increment; 0.98–0.99); and higher in males (1.18; 1.12–1.25). Relative to PPMS-N, hazard was decreased in SPMS-A (0.79; 0.71–0.87) but similar for PPMS-A (1.01; 0.93–1.10) and SPMS-N (0.94; 0.85–1.05). Sensitivity analyses corroborated these results. However, patients with SPMS-A reached EDSS ≥ 7 at younger ages (cumulative probability 30% by 57, vs. 64–66 for SPMS-N, PPMS-A, PPMS-N).

Conclusions

Progressive phase onset is later in SPMS than PPMS. Hazard of disability accrual during the progressive phase is lower in SPMS than PPMS. However, patients with SPMS-A reach wheelchair requirement younger than other progressive phenotypes, reflecting earlier progression onset versus SPMS-N, and greater disability at onset versus PPMS

Background

In relapsing remitting multiple sclerosis (RRMS) inflammatory disease activity decreases with higher age and longer disease duration. The disease modifying treatments available today are aimed at suppressing inflammatory activity and younger age and higher disease activity are associated with larger relative treatment benefits.
At the University Hospital of Umeå, in Västerbotten county, Sweden, >90% of all patients with RRMS are treated with the monoclonal anti-CD20 B-cell depleting antibody rituximab (RTX). In a placebo-controlled phase II study, RTX have displayed high efficacy in suppressing inflammatory disease activity and in several retrospective observational studies RTX shows high effectiveness compared to other disease modifying therapies commonly used. However, there are limited data on disease activity after discontinuation of treatment with RTX.

Objectives

The primary objective is to evaluate effects on inflammatory disease activity (defined as clinical relapses, new cerebral T2 lesions and/or contrast enhancing lesions on MRI) after discontinuation of treatment with RTX in patients with RRMS or possible MS. The secondary objective is to evaluate the effects on inflammatory disease activity after dose reduction to an average of <1000 mg/year in the same patient group.

Methods

In this retrospective observational study data is collected from the Swedish MS registry and medical records. We include all RRMS and possible MS patients ever treated with ≥2 doses and a total of ≥1000 mg of RTX at the University Hospital of Umeå who either; (1) have discontinued treatment at any time (i.e. ≥18 months since last infusion) or (2) have reduced the treatment dose to a mean of <1000 mg RTX yearly.

Results

Preliminary data indicate that 228 patients meet the inclusion criteria. 102 patients (45%) have discontinued treatment and 206 patients (90%) have reduced the dose to <1000 mg/year at some point during the observation period. Further data analysis will include a comparison of annualized relapse rates and inflammatory disease activity on MRI between time on-treatment, time off-treatment and/or time on low-dose treatment.

Conclusions

This study will provide real-world data that may guide clinicians in future treatment decisions for RRMS patients treated with RTX.

Background

Early initiation of disease modifying therapy (DMT) in patients diagnosed with relapsing-remitting multiple sclerosis (RRMS) is recommended for optimal patient outcome. However, there may be multiple barriers to timely DMT initiation. A better understanding of patient-intrinsic factors may help physicians to guide patients during this critical phase of newly diagnosed chronic neurological disease.

Objectives

To determine rates of disease modifying therapy utilization and descriptive and demographic correlates of DMT use in individuals newly diagnosed with multiple sclerosis (MS).

Methods

A cohort of 230 individuals of two metropolitan MS centers was followed longitudinally assessing different psychological domains at 1, 2, 6, 9, and 12 months following their diagnosis of MS. The use of DMT throughout the first year following diagnosis of MS was assessed.

Results

Patients were 70.9% female and 88.2% white with a mean age of 39 years (range 18-71), mean baseline EDSS of 3.9 (range 0-7) and predominantly relapsing-remitting MS (204 RRMS, others were clinically isolated syndrome or not specified). Participants had 15.3 years of education (10-21) and 176 (76.5%) were working (others unemployed, retired, sick leave, disabled or student).

During their first year after MS diagnosis, 133 of 210 (63%) were not on a DMT at 1 month, 46 of 210 (22%) at 6 months and 47 of 201 (22%) patients were not on a disease modifying therapy at 12 months. Not being on a DMT at month 1 was not correlated with employment (r=0.019), years of education (r=-0.042), gender (-0.006), age (0.052) or EDSS (-0.043). Of those individuals who had initiated a DMT at 12 months, 52.4% individuals were treated with first-line injectable DMTs (glatiramer acetate or beta interferon), 35.7% with oral DMT and 11.9% with an infusion DMT (natalizumab or ocrelizumab).

Conclusions

In this prospective observational longitudinal study, initiation of DMT following diagnosis of MS was done in less than half of patients within the first month of the study (which was up to the first 4 months after diagnosis of MS). 22% of participants were not started on a DMT at 1 year. No definite demographic factors associated with time to DMT initiation could be identified in our cohort. Since early initiation of DMT has been associated with improved outcome, this phenomenon deserves further investigation. When treating patients with MS, special attention should be paid to facilitate an early start of DMT.

Background

MS-CQI is the first multi-center improvement research collaborative to improve system-level performance and population health outcomes for people with MS. MS-CQI is a three year study (2018-2020) to evaluate system-level performance variation and improve population health outcomes in MS care. Four MS Centers are participating, following approximately 5,000 people with MS.

Objectives

To describe system-level variation in disease modifying therapy (DMT) utilization for people with MS based on Year 1 (baseline/pre-intervention) results.

Methods

Electronic Health Record (EHR) data from clinical encounters at participating MS centers was used. Participants were adults ≥18 years with MS. DMT utilization was categorized into oral, infusion, and injectable types. Chi-square and adjusted multinomial logistic regression analyses were used to investigate associations between centers and DMT utilization.

Results

2,029 people with MS (PwMS) were included in our analysis: 75.1% female; mean age= 50 years; 87.4% relapsing MS (RRMS). 32.7% were taking an oral, 23.5% infusible, and 43.9% injectable DMT. 23.9% PwMS were not on DMT, and the majority of these were people with RRMS. DMT utilization varied across sites: (1) oral (23-49%); infusion (15.9%-35.8%), and injectable (34.6-55.3%). Adjusting for individual level factors, including MS disease type, disease activity (relapses), demographics, and comorbidities, differences (p<0.01) were observed across centers for proportion received oral, infusible, injectable and no DMT. We also observed differences (p<0.01) across MS types and with increasing age for proportion received oral, infusion, injection, and no DMT treatment.

Conclusions

System-level effects on DMT utilization have not been previously studied and our findings contribute initial evidence that system-level (small area geographic) variation in DMT utilization exists. We also identified that nearly a quarter of PwMS followed by MS-CQI centers were not on DMT treatment and identified a target subpopulation for improvement efforts- people with RRMS not on DMT treatment. Years 2 and 3 of the MS-CQI study involve an evaluation of the effect of system level quality improvement (QI) intervention on population health outcomes for PwMS.

Background

Background:

The prevalence of multiple sclerosis (MS) in Abu Dhabi Emirati population had been reported to be one of the highest on the Arab peninsula. The Ocrelizumab (OC) approved for treatment of a broad spectrum MS sub-types including relapsing-remitting, active secondary progressive, primary progressive disease

Objectives

Objectives:

To assess the Ocrelizumab disease modifying therapy (DMT) efficacy and safety in cohort of MS patients treated in the Eastern region of Abu Dhabi Emirate

Methods

Methods:

Retrospective charts review of MS patients treated with OC at our MS clinic, Tawam hospital from January 2018 till June 2020

Results

Results:

We retrospectively reviewed the course of 20 patients with MS who received OC. The average age of patients was 32 years (19 to 52 years), female/male ratio was 1:1. All patients had a high hyperintense lesions load before OC initiation. It was no clinical relapses on OC treatment, but before OC treatment annual relapse rate was 0.625. One patient showed radiological activity, while the other one had a clinical and radiological relapse diagnosed in the first two weeks since the onset of OC treatment . The majority of MS patients (84.2% ) had no disease activity or disease progression during the OC treatment period. Before OC treatment three MS patients were naive, but the rest of them previously received from one to four DMTs indicating the complicated course and long history of the disease. Ten patients previously were on Natalizumab, 11 were on oral DMTs, 1 was on Rituximab, and one on Mitoxantrone. JCV was positive in 11 patients who were started on OC. The average treatment duration with OC was 16-months, average given doses were 2.6 Eighteen patients were adherent to the treatment, and had regular follow up. The average baseline EDSS before OC treatment was 2.32 (ranging from 0 to 7), while on OC DMT average EDSS became 2.14. Among all patients with MS treated by OC, only one patient had a mild infusion reaction over the observation period. They were no cases of PML in patients who were switched from Natalizumab to OC. During COVID -19 out brake OC regular infusion was postponed for approximately 6 weeks, but none of the patients had a clinical relapse in that time or COVID infection.

Conclusions

Conclusion:

DMT of Multiple sclerosis with Ocrelizumab showed good control of disease activity and the absence of disease progression in our cohort of patients over more than 2.0 years since the onset of treatment. The Ocrelizumab is efficient, feasible and safe DMT for different MS sub-types

Background

Cognitive impairment may reflect damages to brain structures, pathophysiological impairment, [BK1] or both and are usually detected too late to implement an effective preventive therapy

Objectives

The objective of this study was describe and compare the annual percentage of brain volume loss (PBVL) during 3 years in patients with multiple sclerosis (MS) who developed cognitive impairment (CI) vs. patients that did not (noCI)

Methods

prospective cohort study that included recently diagnosed (less than 6 months since first relapse) and naïve relapsing remitting MS patients. Patients were followed for at least 36 months evaluating relapses and EDSS. Magnetic resonance image (MRI) evaluation was done at study entry and then at 12, 24 and 36 months. PBVL was done by SIENA. Cognitive evaluation was done at study entry to exclude patients with cognitive impairment (CI) (defined as patients who scored at least 2 SDs below controls on at least 2 domains) and then at month 36. Annual PBVL between CI and noCI were described and compare. Linear model with generalized estimating equations (GEE) was used

Results

A total of 71 patients were included, mean age 35.4 ± 3 years, mean follow up time 43 ± 5 months. All patients received fingolimod after diagnosis. At month 36, 12% patients were classified as CI. PBVL at year 1 in CI and noCI group was -0.52 (± 0.07) vs. -0.42 (± 0.04), at year 2 was -0.41 (± 0.03) vs. -0.71 (± 0.07) and at year 3 was -0.43 (± 0.05) vs. -0.81 (± 0.05) respectively. PBVL for the entire period (0 to 3 year) in CI and no CI was -1.25 (± 0.11) vs. -2.05 (± 0.12) respectively.

Conclusions

In patients with CI, since the first year a significant difference in BVL was observed that increased almost 2-fold during the 2 and 3 year of follow up. Early differences in BVL were identified in patients that progressed CI vs. patients that did not progressed.

Background

Ocrelizumab (OCR) is a humanized monoclonal antibody targeting CD20-positive B cells. In Denmark, OCR treatment is recommended for patients with highly active relapsing-remitting multiple sclerosis (RRMS) or with early active primary progressive MS (PPMS) and moderate disability.

Objectives

To describe the real-world experience of patients initiating OCR by characterizing baseline demographic and disease attributes, as well as treatment outcomes, of an unselected adult MS population.

Methods

Observational cohort study with prospectively enrolled cases from January 2018 to April 2020 using data from the near complete nationwide population-based Danish Multiple Sclerosis Registry.

Results

Of the 851 patients initiating OCR treatment, 735 (86%) had RRMS, 61 (7%) had secondary progressive MS (SPMS) and 55 (7%) had PPMS. Of all patients, 131 were treatment naïve and, of these, 41 were PPMS. Median disease duration in years was 10.1 for RRMS (IQR 4.4-16.7), 17.8 for SPMS (13.3-24) and 3.9 for PPMS (2.5-7.8). Median baseline Expanded Disability Status Scale (EDSS) score was 3 for RRMS (IQR 2-4), 6 for SPMS (4.5-6.5) and 3.5 for PPMS (2.5-4.5). In the year prior to OCR initiation, 50% of the RRMS population had at least one relapse on another disease-modifying therapy (DMT); of these, 58% were on high efficacy DMT. Compared to RRMS, SPMS patients were older, had higher EDSS, and 34% had at least one relapse in the two years prior to OCR start. Fifty-five (90%) were previously treated with DMT, and 69% were on DMT in the year before OCR start.

The median OCR therapy duration was 0.9 years. During follow-up, 93% of all patients were relapse-free, and five patients reported more than one relapse. Out of 18 treatment discontinuations that occurred, two were due to disease breakthrough and nine were due to adverse events. Of the 383 patients with an EDSS score between 6 and 12 months, 80 (21%) showed EDSS improvement, 266 (69%) remained stable, and 37 (10%) experienced worsening. Of the 63 reported adverse events, the most common were upper respiratory tract infections (15), allergic reactions (7), and herpes simplex infections (6).

Conclusions

In this nationwide study, we present all Danish patients receiving OCR therapy in a real-world setting. Patient characteristics differed for RRMS, PPMS and particularly the SPMS group. With reservations for the short follow-up time, 93% of all patients were relapse-free and only 10% experienced disability worsening.

Background

Multiple sclerosis (MS) is a chronic, mostly progressive, inflammatory, demyelinating, and neurodegenerative disorder of the central nervous system (CNS). There are various phenotypes of the disease, with the phenotype of relapsing-remitting (RR) multiple sclerosis being more frequent up to 85%, followed by the progressive primary and secondary forms with approximately 10%. Currently there is no treatment in the Mexican Social Security Institute for progressive forms, rituximab has been shown to be a useful drug in RR forms, there are no studies demonstrating effectiveness and safety in progressive forms of the disease.

Objectives

To determine the effectiveness and safety of rituximab treatment in patients of the Neurology service with a diagnosis of progressive multiple sclerosis at the Dr. Antonio Fraga Mouret Hospital from January 2010 to January 2019.

Methods

Retrospective, observational, longitudinal cohort study that included patients older than 18 years with diagnoses of primary and secondary progressive multiple sclerosis who had been managed with rituximab, evaluated with the Extended Disability Status Scale (EDSS), number of active lesions in MRI as well as the rate of progression before and after the application of rituximab at 12, 18, 24 and more than 24 months after application, using the Wilcoxon signed rank test.

Results

Significant result before and after the application of rituximab on the EDSS scale p = 0.003, as well as with respect to the number of active lesions p = 0.005 and regarding the rate of progression p = 0.001. Adverse effects of infusion with rituximab occurred in 1 patient (1.6%) with recurrent urinary tract infection, 4 patients presented a relapse after administration of rituximab (6.3%), while 60 patients (93.8%) did not present a relapse after rituximab treatment. The EDSS prior to the application of rituximab was found to have a mean of 6.5, compared to the subsequent EDSS 6.0.

Conclusions

Treatment with rituximab significantly improves the evolution of patients diagnosed with progressive primary and secondary multiple sclerosis, showing effectiveness and safety during its application.

Background

The increasing availability of disease modifying therapies (DMTs) and updated diagnostic criteria could impact on diagnostic rates and patient outcomes of multiple sclerosis (MS).

Objectives

We aimed to evaluate the use of DMTs in MS patients in Hong Kong, and the effectiveness and outcomes based on onset year and timing of DMT initiation.

Methods

In this cohort study, we identified 159 relapsing-remitting MS (RRMS) patients from a prospective registry and evaluated their medical records. Patients who were treated with DMT for at least one year were analysed (N=139, 87%). We evaluated the number and reasons of switching DMTs, and disease control. Among patients who had MRI performed within 3 months before DMT initiation (N=95), we evaluated predicting factors of disability progression and DMT switch, and compared differences among patients with different year of disease onset, and duration from onset to DMT initiation.

Results

Of 139 patients, the median disease duration, onset to DMT initiation, and treatment duration were 9 years, 2 years and 5 years, respectively. 67% patients had switched DMT, near half was due to disease progression; 35% of all patients were stable on their second DMT, while 13% had switched >3 times. 74% patients remained relapse-free on their latest DMT. A longer disease duration was significantly associated with disability progression [odds ratio(OR) 1.22 per year, p<0.01]. Shorter duration from disease onset to DMT initiation [OR=0.887, p=0.044] and failure to achieve no evidence of disease activity-3 (NEDA3) at 1 year after DMT initiation [OR=0.36, p=0.024] were significantly associated with DMT switch. Of note, patients with disease onset in 2012-2018 (when DMT could be fully reimbursed), as compared to those in 2001-2011, had significantly shorter duration from onset to DMT initiation (0.69±1.15 vs 4.65±4.07 years, p<0.01), and less patients having disability progression at last visit (9.6% vs 30%, p=0.02). Patients who started DMT within 1 year from disease onset, compared to those who started between 1-5 years, had significantly shorter disease duration (5.68±3.60 vs 8.52±4.23 years, p<0.01), higher pre-treatment annualized relapse rate (ARR) (2.44±3.68 vs 0.87±0.73, p=0.014), and lower latest ARR (0.09±0.20 vs 0.29±0.60, p=0.047).

Conclusions

Our study shows current DMTs are effective in reducing relapse rate of MS patients in South China, and earlier commencement of DMTs may improve disease control.

Background

Dimethyl fumarate (DMF) is an FDA approved drug for relapsing forms of multiple sclerosis. Currently, there is limited data analyzing the safety and efficacy of DMF in progressive multiple sclerosis (PMS) population. A combination of immunomodulatory and neuroprotective effects demonstrated with DMF could theoretically benefit this subset of patients.

Objectives

To analyze the safety and efficacy of dimethyl fumarate in patients diagnosed with progressive forms of multiple sclerosis.

Methods

We conducted a single-center retrospective observational analysis of patients with PMS assessing the safety and efficacy of DMF. We used Cox proportional hazards models to compare the time to sustained worsening and improvement on the Expanded Disability Status Scale (EDSS) and timed 25-foot walk (T25FW) between patients treated with DMF and glatiramer acetate (GA) for at least one year. A multivariable analysis adjusting for age, sex, disease duration, and baseline EDSS was also performed.

Results

Eighty-eight patients were included in this study, 46 patients in the DMF group and 42 in the GA group. Safety and tolerability of GA and DMF were consistent with established profiles. There was a non-significant reduction in sustained EDSS and T25FW progression in the DMF group compared to the GA group after adjustment (HR=0.74; 95% CI: 0.32, 1.70; p=0.46 and HR=0.51; 95% CI: 0.21, 1.21; p=0.12, respectively). Sustained EDSS improvement showed a significant difference in the DMF group compared to the GA group (HR=4.23; 95% CI: 1.09, 16.42; p=0.04) after adjustment.

Conclusions

In a well-characterized PMS population, DMF showed a consistent though non-significant reduction of disease progression metrics and a significant increase in proportion of patients experiencing sustained EDSS improvement compared to patients treated with GA. The small sample precluded definitive determination though suggested that further study of DMF in PMS is warranted.

Background

Intravenous and subcutaneous cladribine has been used in multiple sclerosis since 1993. While oral cladribine is now approved by the EMA and FDA, the dosing of intravenous and subcutaneous cladribine is equivalent to twice that given with oral cladribine and in half the time. Based upon its mechanism of action, prolonged effect, and significant CNS penetration, we felt MS patients with aggressive or progressive disease would be ideal candidates for this medication and have been using cladribine since 1995.

Objectives

This study reports the efficacy and safety of a large cohort of multiple sclerosis (MS) patients receiving intravenous or subcutaneous cladribine. The primary objective is assessing the clinical outcomes. The secondary objective is assessing hematologic abnormality, infection, and cancer rates.

Methods

This is a retrospective cohort study of relapsing-remitting (RRMS), secondary progressive (SPMS), and primary progressive (PPMS) MS patients treated with intravenous or subcutaneous cladribine at the Rush Multiple Sclerosis Center from January 1995 to May 2019. Each round of cladribine was 0.7 mg/kg given over 5 days. Subsequent rounds were given once the total white blood cell count was normal. Full course consists of 4 rounds, or a total dose of 2.8 mg/kg (equivalent to 5 mg/kg of oral cladribine). Additional intravenous or subcutaneous doses were administered based upon new clinical or MRI activity.

Results

There were 247 patients in the cohort with 2198 patient-years of follow-up. Mean age of patients and disease duration at the time of first dose was 42.9 and 11.2 years, respectively. Mean follow-up after the first dose was 7.6 years. RRMS and active SPMS comprised 51.2% while non-active SPMS and PPMS made up 43.9% of patients. A full course was completed by 77.3% of patients. At least one additional dose of cladribine was given to 24.6% of patients at a mean of 3.5 years after the fourth round. Clinical outcomes were 46.4% had sustained clinical improvement, 37% were stable, and 16.7% continued to progress. Mean duration for stability or improvement after a full course was 2.3 and 3.6 years, respectively. Mean nadir of the white blood cell count was 3.3 K/uL. Mean maximum time to Grade 1 leukopenia was 0.6 months. Mean nadir lymphocyte count was 0.27 K/uL. Mean maximum time to Grade 0-1 lymphopenia was 8.7 months. For serious adverse events, there were 13 cases of cancer (0.59 cases per 100 patient-years), 3 serious infections, 6 cases of herpes zoster, 2 cases of myelodysplastic syndrome, and 14 deaths.

Conclusions

Intravenous and subcutaneous cladribine resulted in most patients having temporary clinical stability or improvement of their most disabling MS symptoms. Most patients experienced a transient leukopenia and lymphopenia. Overall, the treatment was well tolerated with no unexpected serious adverse events.

Background

There are different treatments used for multiple sclerosis. Observational data generates evidence about what are the efficacy, safety, tolerance, adherence and management of these drugs in real world.

Objectives

To describe the experience with the use of teriflunomide in a specialized multiple sclerosis (MS) unit from September 2015 to May 2020

Methods

Epidemiological analysis of MS patients treated with teriflunomide from September 2015 to May 2020 in a specialized MS unit, together with the reasons to start and to stop with the treatment and the clinical evolution of the patients.

Results

112 patients (70% women, 30% men) were treated with teriflunomide from September 2015 to May 2020. The mean age was 42 years (range 21-68 years). Teriflunomide was the first MS treatment in >50% of cases and the others had been treated with other MS treatments with moderate efficacy, mainly interferons and glatiramer acetate. During this period, the drug was discontinued in 38 patients (34%): 27 patients for disease activity (relapses or new brain o spinal core lesions), 5 for adverse events, 4 for developing a progressive form of the disease, 2 for pregnancy desire, 1 for personal decision. There have been no severe adverse events. 3 patients had severe diarrhea and 2 peripheral neuropathy. 5 patients had significant hair fragility that was treated but did not cause discontinuation of teriflunomide.

Conclusions

Teriflunomide is an optimal, suitable and effective drug for relapsing-remitting with known and mild-to-moderate adverse events.

Background

Limited data is available regarding the effect of disease modifying therapies on cognitive decline and brain volume change in real world multiple sclerosis (MS) patients. Novel deep gray matter (DGM) quantitative susceptibility mapping (QSM) techniques have not been extensively studied in MS.

Objectives

To assess cognitive performance, magnetic resonance imaging (MRI) brain volumetrics and deep gray matter QSM at baseline, 6 months, 12 months and 24 months in a real world relapsing MS patient cohort treated with fingolimod, referenced to age- and sex-matched healthy controls (HCs).

Methods

Relapsing MS patients from 2 centers (Sydney, Australia and Buffalo, United States of America) were recruited to this observational, prospective study following the decision by their treating neurologist to commence fingolimod therapy. Neurological assessment (Expanded Disability Status Scale (EDSS)), cognitive testing (Minimal Assessment of Cognitive Function (MACFIMS)), and 3 tesla (3T) MRI brain acquisition occurred at baseline, 6 months, 12 months and 24 months. Matched HCs were recruited prospectively from both centers and were followed longitudinally at the same time points.

Results

The relapsing MS (n = 50) and HC (n = 41) cohorts were well matched for age and sex. With fingolimod treatment, clinical relapse rates and MRI lesion activity were significantly reduced, and the EDSS remained stable, in the relapsing MS patient group. Baseline DGM volumes, but not whole brain volumes, were significantly lower in the patient cohort compared to the HC cohort (p < 0.05). Longitudinal DGM volume changes were not significantly different between the groups. Between the baseline and 24 month time points the percentage whole brain atrophy, as measured using Structural Image Evaluation using Normalisation of Atrophy (SIENA), was higher in the patient group (mean: -1.25%) compared with the HC group (mean: -0.44%) (p = 0.006). Baseline thalamus QSM was significantly lower, and the baseline caudate and pallidus QSM were significantly higher, in the MS patient group (p < 0.05). Longitudinal DGM QSM changes were not significantly different between groups. Baseline cognitive performance was worse in the MS group (p < 0.05), but longitudinal cognitive stability/improvement was not significantly different between the two groups.

Conclusions

This real world prospective observational study suggests that fingolimod reduced clinical relapses and MRI lesion activity, and stabilized cognitive performance in the relapsing MS patient cohort. DGM volume and DGM QSM change rates were comparable between the fingolimod treated relapsing MS patients and the age- and sex-matched healthy controls. Whole brain atrophy between baseline and 24 months was greater in the fingolimod treated MS patients compared with HCs, but the differences were not significant for other epochs; further subgroup analysis is underway to explore this finding.

Background

Data generated from electronic health records (EHRs) offer insight into real-world care of people with multiple sclerosis (MS). Data extracted most readily from EHRs include templated or administrative health information (e.g., MS International Classification of Diseases codes). However, clinical data like disease subtype and characteristics are unlikely to be captured systematically. FlywheelMS is a novel patient-centered study with the aim of digitizing health records of patients with MS and extracting information not readily available in existing EHRs.

Objectives

To evaluate patient characteristics and the prevalence of MS subtypes (i.e., relapsing-remitting MS [RRMS], secondary progressive MS [SPMS], primary progressive MS [PPMS], progressive relapsing MS [PRMS]) in the FlywheelMS cohort and to compare them with existing real-world data sources.

Methods

Adults with MS are recruited across the US via advocacy groups, social media and healthcare professionals. Supervised machine learning with human curation is used to retrieve, digitize and abstract medical records, which are collected as far back as are available and prospectively up to 5 years after enrollment. The most recent non-negated MS subtype from neurology visit records was used as a proxy for the prevalent subtype. Summary statistics were calculated and compared with other MS cohorts.

Results

As of March 1, 2020, 2,389 patients with MS with 24,362 neurology visits across 3,093 neurologists have enrolled in FlywheelMS. Data on MS subtype were available for 973 patients (40.7%); this proportion will increase as abstractions continue. RRMS accounted for 78.9% of patients, followed by SPMS (12%), PPMS (7.3%) and PRMS (1.7%). These findings were comparable to the MSBase Registry (RRMS=76.9%, SPMS=13.0%, PPMS=8.0%, PRMS=2.2%; Kister et al., J Neurol Sci 2012) and NARCOMS Registry (RRMS=65.6%, SPMS=25.1%, PPMS=9.3%; Salter et al., Mult Scler 2018). Mean [SD] age at mention of MS subtype and percent female distribution were as follows: RRMS (46.4 [10.9] years, 80.4%), SPMS (56.4 [9.6] years, 81.2%), PPMS (53.9 [10.7] years, 62.0%), PRMS (mean 53.9 [5.5] years, 82.4%).

Conclusions

The prevalence of MS subtypes in the digitized health records of patients in FlywheelMS was comparable to other real-world data sources. Digitizing and machine-learning guided abstraction of patient healthcare records in MS yields important data about clinical features not readily available in other EHR data sets.

Background

In secondary progressive multiple sclerosis (SPMS), reduction in the rates of disability accrual after starting disease modifying therapy (DMT) has largely been limited to patients with ongoing inflammatory activity. A delayed treatment effect, termed therapeutic lag, may obscure therapeutic benefits in SPMS.

Objectives

To compare the effect of high and low efficacy DMT on disability outcomes in patients with recently active and inactive SPMS after accounting for therapeutic lag.

Methods

Using data from MSBase, a multinational MS registry, and OFSEP, the French MS registry, we identified patients with SPMS as per a previously validated objective definition. We identified patients treated with high- (natalizumab, alemtuzumab, mitoxantrone, ocrelizumab, rituximab, cladribine, fingolimod) or low-efficacy (interferons, glatiramer acetate, teriflunomide) DMT after SPMS onset. Based on our previous work, an individualised estimate of duration of therapeutic lag was calculated for each patient. Only events that occurred after the estimated therapeutic lag period were included in the analysis. Propensity score matching was used to select groups with comparable baseline characteristics. Disability and relapse outcomes were compared in paired, pairwise-censored analyses adjusted for visit density.

Results

Of 7359 patients with SPMS, 1000 patients fulfilled the criteria for study inclusion (510 active SPMS, 490 inactive SPMS). For the relapse outcomes, patients with active SPMS treated with high-efficacy DMTs experienced lower probabilities of relapses than low-efficacy DMTs (hazard ratio [HR] 0.7 [95%CI 0.5-0.9], p=0.006). Patients with inactive SPMS had similar probabilities of relapses in the high and low efficacy DMT groups (0.8 [0.6-1.2], p=0.39). No difference in the risk of 6-month sustained disability accumulation, or proportion of patients reaching EDSS>=7, was observed between groups when accounting for therapeutic lag.

Conclusions

The risk of disability accumulation in SPMS seems to be comparable in patients treated with high- and low- efficacy DMT. High efficacy DMT is superior to low efficacy therapy in reducing relapse activity in patients with active SPMS, but not those with inactive SPMS. Pre-treatment inflammatory activity, clinical or radiological, is a treatable target in SPMS which may benefit from higher-efficacy anti-inflammatory therapies.

Background

The natural history of progressive multiple sclerosis (MS) is one of evolving paraparesis, then tetraparesis and ultimately bulbar dysfunction. Recently, it was proposed that progressive MS is a length dependent axonopathy due to random incremental damage throughout the central nervous system, and that “this length-dependent process might be explained by stochastic statistical phenomena that interact with anatomical, pathological and biological factors”.

Objectives

To determine the prevalence of body part involvement in a large MS population and whether such prevalence is related to axonal length.

Methods

A questionnaire pack including a pictorial mannequin upon which body part involvement could be indicated was administered to patients with definite MS as part of the TONiC study, a multicentre, UK study of factors affecting quality of life in MS. Subject characteristics were determined by a physician at study enrolment. A logistic regression model was developed adjusting for demographic factors to determine probabilities of body part involvement and whether probabilities varied by disease factors and their relationship to axonal length. Average lengths of neuronal pathways from cortex to points along the CNS were taken from the literature.

Results

4204 records were available for analysis. Mean age was 50.2 years, median disease duration 11.2 years. 73% were female, 65% had relapsing, 11% primary progressive and 24% secondary progressive disease. 50% were fully ambulatory (EDSS 0–4), 38% EDSS 4.5–6.5, 7% EDSS 7.0–7.5, 5% 8.0–9.5. Prevalence decreased in the following order: left lower limb, right lower limb, bladder, left hand, right hand, vision, left arm, right arm, speech, neck, swallowing. Axonal length was strongly associated with body part prevalence with an odds ratio of 4.2 per standard deviation of axonal length (23.95cm) for patients with progressive disease and 2.7 for those with relapsing disease. Only weak clustering of body parts was found with correlation coefficients of the model residuals ranging between -0.28 and 0.35, the strongest being between ipsilateral hand, arm and lower limb.

Conclusions

We demonstrate a probabilistic hierarchy of body parts affected by MS in a large cross-sectional sample of patients. The hierarchy progresses from distal to proximal segments and lends some clinical support to the length dependent axonopathy theory of MS.

Background

Multiple sclerosis (MS) is a demyelinating condition of the central nervous system of complex aetiology. One such factor implicated in its onset and progression is diet and because of this a number of diet program have been proposed which their creators assert will improve MS.

Objectives

This study sought to investigate the prevalence and characteristics of adherence to several popular diets proposed for people with MS.

Methods

The international observational cohort study, the HOLISM Study, has measured lifestyle and clinical characteristics over 5 years of follow-up. At the 5-year review, 952 participants were queried as to their adherence to 6 diet programs – the Overcoming MS (OMS), Wahls Elimination, Swank, McDougall, Ashton Embry Best Bet, and Palaeolithic diets – adherence constrained to those doing so for at least 12 months. Adherence was defined by two dichotomisations of the 5-point Likert at 3 and 4 of 5. Lifestyle characteristics of adherence to each diet were assessed by log-binomial regression.

Results

OMS adherence was common, with roughly 30-40% adhering, while Swank (5-6%) and Wahls (2-3%) adherence was less frequent and other diets even less (<2%). Higher BMI and smokers were less likely to follow OMS, while participants who were more active, those consuming alcohol or using vitamin D/omega-3 supplements, and who meditated were more likely to adhere. OMS adherers were less likely to consume meat or dairy. Swank adherence was higher among those who were more active and less so among those of higher BMI, but otherwise did not differ by any lifestyle characteristics. Wahls adherence was more common among those consuming alcohol and those who consumed meat but less common among those consuming dairy.

Conclusions

OMS and to a lesser extent Swank and Wahls diets had material followings in this international cohort. Though it was expected all diet adherence would generally track with healthier lifestyle, there was some variability, suggesting that adherence to these diet programs is more likely in certain subgroups.

Background

Neutralizing anti-drug antibodies (NAbs) to interferon beta (IFNβ) develop in up to 47% of multiple sclerosis (MS) treated patients inhibiting treatment effect of IFNβ. However, the long-term effect of NAbs remain unknown.

Objectives

To investigate the long-term consequences of high titre NAbs to IFNβ on disease activity and progression in MS patients.

Methods

An observational study including data from all IFNβ treated MS patients with sufficient NAb test results from the Swedish MS registry. Patients were classified into either confirmed ‘high titre’ or ‘persistent negative’ groups and analysed for differences in disease activity and progression over time.

Results

A total of 197 high-titre and 2907 persistent negative patients with 19969.6 follow up years of data were included. High titre NAbs were associated with a higher degree of disease activity at baseline. However, even when accounting for this, the presence of high titre NAbs were also associated with higher disease activity during IFNβ treatment. This persisted even after the next DMT start, suggesting that earlier high titres may partially reduce the effect of later treatments. No difference was found in confirmed disability progression.

Conclusions

High titre NAbs to IFNβ are associated with higher disease activity, persisting even after IFNβ discontinuation or switch. These results support use of highly efficient treatment earlier, to avoid these complications.

Background

Cladribine tablets were approved in Canada in November 2017. All patients prescribed cladribine tablets in Canada are enrolled upon their consent in the adveva patient support program (PSP), which provides drug education, assistance with reimbursement and patient support services.

Objectives

To examine the demographics and treatment history of patients initiating cladribine tablets in Canada, assess the discontinuation rate over the two-year treatment and describe reported adverse events (AEs).

Methods

Analysis of data routinely collected by adveva nurses and all reported AEs from Dec2017 to Jan2020. Patients were included if they consented to enroll in the adveva PSP. They were contacted at enrollment and periodically therafter. Follow-up stopped when treatment was completed/discontinued.

Results

Overall, 1864 patients enrolled in the program; 1373 were female (74.4%) and mean age was 41.54 years (standard deviation [SD]: 10.34). None of the patients were treatment naïve; most (n=1191; 63.9%) had received only one prior disease modifying drug (DMD). The most recent prior DMDs were glatiramer acetate (23.1%), dimethyl fumarate (20.4%), teriflunomide (16.5%), fingolimod (10.9%), and subcutaneous interferon beta-1a (10.4%). Of 1864 enrolled, 1679 (90.1%) had completed pre-treatment evaluation. Of those, 1415 (84.3%) started year-1. Among those, 483 (34.1%) started year-2 and 394 (27.8%) completed it. Mean time to year-2 initiation was 12.75 (SD: 1.27) months. Among all patients who had started year-1 treatment, 38 (2.69%) reported discontinuation. Among those, 26.3% discontinued within <6 months, 52.6% between 6-12 months and 21.1% at ≥12 months. Main reported reasons were: 28.9% unknown, 21.1% AE other than flu-like syndrome and lymphopenia, 18.4% worsening disease, 10.5% patients decision, and 10.5% family planning/pregnant. A total of 843 patients (59.6%) reported at least one AE. Among the total AEs report (n= 3525)the most frequent were fatigue (8.0%), headache (5.4%), nausea (4.7%), and lymphocytopenia (2.5%).

Conclusions

The Canadian adveva program presented a high enrolment rate. Cladribine tablets were associated with a high continuation rate and most patients successfully self-adminstered the drug. Reported adverse events were not severe.

Background

Natalizumab is an effective disease modifying therapy (DMT) for relapsing remitting multiple sclerosis (RRMS). However, it is associated with an increased risk of progressive multifocal leukoencephalopathy (PML). Nine confirmed cases of PML have been reported in patients using ocrelizumab, another effective DMT for MS. In 8 cases, patients previously used natalizumab or fingolimod, likely causing PML. This phenomenon has been described as carry-over PML.

Objectives

To describe the disease course of carry-over PML after switching from natalizumab to ocrelizumab in two patients with RRMS.

Methods

Two case reports with 1 year of follow-up and retrospective longitudinal measurements of serum neurofilament light (sNfL) levels and B-cell count. Both patients provided informed consent.

Results

Regular follow-up showed no disease activity under natalizumab treatment and both patients switched to ocrelizumab following a stringent safety protocol including two additional MRI brain scans and cerebrospinal fluid (CSF) analysis. Both patients received a single infusion of 300 mg ocrelizumab before PML diagnosis. PML was diagnosed ±11 weeks (case 1) and ±13 weeks (case 2) after the last natalizumab infusion. At that time, both patients were asymptomatic. In retrospect, subtle signs suggestive of PML were already present on MRI under natalizumab treatment. One patient developed PML despite extended interval dosing of natalizumab. Both patients developed mild immune reconstitution inflammatory syndrome (IRIS) despite complete B-cell depletion. SNfL levels were 9.9 pg/ml (reference range 1-15 pg/ml) for case 1 and 16.7 pg/ml (reference range 2-18 pg/ml) for case 2 at the time of PML diagnosis and increased to 15.0 pg/ml and 36.5 pg/mL during PML-IRIS. SNfL was not elevated before radiological diagnosis of PML. PML-IRIS lesions stabilized after treatment with mefloquine and mirtazapine followed by methylprednisolone with sNfL levels of 9.0 pg/mL and 12.3 pg/mL, respectively. One patient reported no clinical symptoms and one patient only mild clinical symptoms with full recovery during the disease course of PML-IRIS. Both patients continued with ocrelizumab when B-cells started to repopulate ±10 months after the first ocrelizumab infusion.

Conclusions

The clinical course of carry-over PML was mild in both patients, suggesting that B-cell depletion did not aggravate PML-IRIS in these two patients.

Background

North American Registry for Care and Research in Multiple Sclerosis (NARCRMS) is a longitudinal registry studying the course of MS in the disease-modifying era.

Objectives

To examine motor performance metrics of upper and lower extremity function in NARCRMS participants at enrollment, using the Expanded Disability Status Scale (EDSS) and 25-foot walk times.

Methods

Recruitment began in 2016 and by June 24, 2020, 737 patients were enrolled at 25 MS sites across the US and Canada. People with any sub type of MS within 15 years of disease onset and an EDSS of up to 6.5 are eligible for enrollment. Various clinical metrics are collected including motor performance for upper and lower extremities. Our initial observations about EDSS, 25-foot timed walk and the 9-hole peg test are reported below

Results

EDSS and 25-foot walk times were available in 632 patients and upper extremity function in 609 patients. A mean walking speed of 4.96 seconds was recorded in patients with an EDSS of 0 (n=105). 5.11 was the mean speed until an EDSS of 3.0 (n=39) where a mean speed of 5.41 seconds was recorded. Walking truly became affected at an EDSS of 3.5 (n=27) where a mean speed of 6.48 seconds was recorded. Thereafter mean speed progressively declined at every EDSS increase. For an EDSS of 4.0 (n=28), mean speed was 7.78 seconds; for an EDSS of 4.5 (n=6), mean speed was 9.16 seconds and continued to increase until an EDSS of 6.5 (n=11) where mean speed was 19.1 seconds. For the 9-hole peg test, patients with an EDSS of 0 (n=101) had a mean speed of 20.3 seconds in the dominant and 21 seconds in the non-dominant hand. Hand function remained unimpaired until an EDSS of 2.0 and significant slowing occurred in patients with EDSS ranging from 2.5 to 6.5. For an EDSS of 2.5 (n=44), mean speed was 25.3 seconds in the dominant and 24.4 seconds in the non-dominant hand. For an EDSS of 4.0 (n=26), mean speed was 26.3 seconds in the dominant and 26.0 seconds in the non-dominant hand. For an EDSS of 6.5 (n=11), hand function had declined to a mean speed of 40.1 seconds for the dominant and 56.4 seconds for the non-dominant hand.

Conclusions

A linear correlation of the 25-foot walk speed to EDSS increases was remarkable, reiterating the commonly held belief that the EDSS is a “walking scale”. Decline in hand function at an EDSS of 2.5 was unexpected since hands are often perceived to be unaffected early in MS and seldom observed as impaired by patients. Progressive decline of hand function at every EDSS increase would suggest that the 9-HP test is a good marker of declining hand function and should be included in clinical monitoring of patients.

Background

Extending the natalizumab interval after the 24th administration could reduce the risk of progressive multifocal leukoencephalopathy (PML) without efficacy reduction.

Objectives

To evaluate the non-inferiority of the efficacy of an extended interval dosing (EID) regimen compared with the standard interval dosing (SID) of natalizumab regarding the multiple sclerosis (MS) MRI activity.

Methods

It is an observational, multicenter (14 Italian centers), retrospective cohort study, starting from the 24th natalizumab infusion to the loss of follow-up or 2 years after baseline. Patients were grouped in 2 categories according to the mean number of weeks between doses: < 5 weeks, SID; ≥ 5 weeks, EID. Three hundred and eight patients were enrolled. Median dose interval (MDI) following 24th infusion was 5 weeks, with a bimodal distribution (modes at 4 and 6 weeks).

Results

Two hundred and sixteen patients were in the SID group (MDI = 4.4 weeks) and 144 in the EID group (MDI 6 weeks). The risk to develop active lesions on MRI is similar in SID and EID groups during the 6 and 12 months after the 24th natalizumab infusion, respectively 2.98% (95% CI: 0.56-5.40) vs 3.32% (95% CI: 0.00-6.65%) [p=0.88] and 6.65% (95% CI: 3.02-10.29) vs 5.67% (95% CI: 1.76-9.58%) [p=0.73]. The EID regimen does not increase the occurrence of MRI activity after 6 and 12 months.

Conclusions

There is no evidence of a reduced efficacy of natalizumab in an EID setting regarding the MRI activity. This observation confirms previous clinical results and together with the increasing evidence of a reduced risk of PML associated to an EID regimen, supports the need of a bigger randomized study to assess the need to change the standard of the natalizumab dosing schedule, in order to better manage JCV-positive patients after 24 doses of natalizumab.

Background

Natalizumab proved to be very effective in patients with active relapsing-remitting multiple sclerosis but harbors the risk of progressive multifocal leukoencephalopathy (PML), especially in combination with specific risk factors. Accordingly, a safe and an equally effective therapeutic alternative is warranted in this patient group. A high efficacy therapy for Relapsing Multiple Sclerosis are cladribine tablets, representing a short course oral therapy. It has been approved in Europe since 2017 and in the USA since April 2019.

Objectives

Safety of switching from natalizumab to cladribine tablets has been investigated in a limited number of patients and with limited observational time. We therefore analyzed this safety issue with a longer follow-up time in the subgroups of post-natalizumab patients in 2 non-interventional studies (NIS).

Methods

46 patients who switched from natalizumab to oral cladribine were reviewed. They originated from 2 cohorts analyzed separately: 23 patients each from the still ongoing NIS CLEVER (in Germany, 24 weeks follow-up as per study duration) and CLADQoL (in Germany and Austria, mean follow-up 11 months). Different study designs accounted for different timings in data collection. Patients were closely monitored, and data was collected regarding MS relapses, disease progression, or possible adverse events.

Results

The NIS CLEVER provides data from 23 patients (mean age 41.6 years; 78% female; 87% RRMS). The most frequent reason for therapy switch was increased JCV antibody titer/risk of PML or lack of efficacy. Median time on natalizumab was 26.6 months and median gap between therapies 3.2 months. 1 out of 15 evaluable patients at week 24 experienced relapses. For 7 patients at least one AE was reported and no SAE.

The NIS CLADQoL provides data from 23 patients (mean age 38.8 years; 70% female; 91% RRMS). The most frequent reason for therapy switch was increased JCV antibody titer/risk of PML. Median time on natalizumab was 40.1 months and median gap between therapies 3.4 months. 2 out of 10 evaluable patients at month 12 experienced relapses. 6 patients experienced at least one AE and 3 patients one SAE (Anterior Myocardial Infarction (among underlying risk factors), Multiple sclerosis relapse, Dyspnoea).

Conclusions

Based on data from 46 patients, switching from natalizumab to cladribine tablets continued to be safe in a larger patient population and after a longer follow-up. Especially no cases of PML were observed.

Background

MSProDiscuss^TM is a validated, physician-completed tool aimed at facilitating physician–patient conversation on signs of progression in multiple sclerosis (MS). A set of weighted questions on relapses, symptoms and their impacts as experienced by the patient generate a traffic light system output to aid the discussion. The tool is available online at www.msprodiscuss.com.

Objectives

Evaluate the usability and usefulness of MSProDiscuss in discussing disease progression in daily clinical practice.

Methods

An online qualitative survey consisting of individual questionnaires completed by healthcare professionals (HCPs) after using MSProDiscuss in patient consultations and a final questionnaire to capture overall experience on the tool was conducted in 34 countries. General feedback and recommendations for improving the tool were also collected.

Results

In total, 301 HCPs participated in the survey. The HCPs first completed individual questionnaires after using MSProDiscuss on 6974 MS patients and then a final questionnaire. In 97% (initial questionnaire, i) and 98% (final questionnaire, f) of the time MSProDiscuss was used, the time taken to complete the tool was considered satisfactory (1-4min). The questions were found to be comprehensible in 94% (i) to 97% (f) of cases, and HCPs are willing to use the tool again in the same patient 91% (i) of the time. MSProDiscuss was also useful in discussing MS symptoms and its impact on daily activities (88% i / 92% f) and cognitive function (79% both i and f) and in discussing progression in general (88% i / 90% f).

Moreover, in the final questionnaire, 95% agreed that the questions were similar to those asked by a HCP in a regular consultation. MSProDiscuss was also found to be helpful for understanding the impact of MS symptoms on daily activities (91%) and cognitive function (80%). Overall, 92% of the HCPs would recommend MSProDiscuss to a colleague; 92% think that it is feasible and 86% are willing to integrate MSProDiscuss into their clinical practice. Key recommendations were to allow for longitudinal follow-up, expand on cognitive assessments, and provide a patient-completed version. These have been considered for implementation in the updated version of MSProDiscuss.

Conclusions

The survey results established MSProDiscuss as useful and easy to use tool to facilitate patient-physician discussion of MS progression by structured capturing of patient clinical profile. Most HCPs were willing to integrate MSProDiscuss into their daily clinical practice.

Background

The early diagnosis of Multiple Sclerosis (MS) is important for prognosis. On September 20, 2017 Hurricane Maria (HM) passed through Puerto Rico (PR) leaving severe devastation on its path. The electric infrastructure on the island collapsed, gasoline was rationed, medications were scarce and daily living was a challenge for patients with chronic conditions. The island has a high prevalence of MS (70.6/100,000), approximately 156 neurologists and 69 hospitals, most of which were not connected to the electric grid or habitable after the hurricane. Due to the lack of fully operational hospitals and medical offices, patients in need of medical attention did not have many options.

Objectives

We aim to highlight the effects of Hurricane Maria natural disaster in the diagnosis and treatment of an MS patient in Puerto Rico.

Methods

A case review was performed to describe the diagnosis process of a patient during the aftermath of Hurricane Maria on the island.

Results

A 41 y/o Puerto Rican woman had an episode of hemi paresthesia when she was 20y/o it was associated with stress and disregarded. Two weeks prior to HM she was presenting diplopia, internuclear ophthalmoplegia, ataxia and fatigue which worsened immediately after the event. Patient went to a local hospital but she was only referred to a neurologist and discharged. She decided to go on board the USNS Comfort (USNSC) due to the unavailability of medical appointment with neurologists on the island. Due to clinical signs presented and history of symptoms, MS was suspected, but no functional MRI facilities were available to confirm diagnosis. Methylprednisolone was administered and improvement of symptoms was observed. Diagnosis was made without MRI to confirm lesions. Fingolimod was recommended as treatment, but it was not available due to the scarcity of resources and MS treatments. Eventually, fingolimod was provided to the patient. Follow-up with a neurologist for evaluation and MRI of brain performance were advised. Five months after the hurricane, the MRI showed periventricular white matter lesions, some juxtacortical lesions and a single callosal lesion that were not active. Also, black hole was present in the right peri-atrial white matter supporting diagnosis.

Conclusions

This case demonstrates the importance of disaster guidelines for the management of possible diagnosis of MS, availability of functioning MRI facilities and consequent availability of treatment in the hope of preventing progression on these patients. Future work could include creation of collaborations between pharmaceutical companies and MS foundations to receive and distribute DMT samples in case of natural disasters.

Background

Sex and race seem to influence multiple sclerosis (MS) prognosis. Men with MS overall appear to have a worse prognosis than women with MS. Black (African American) MS patients are believed to have a worse prognosis than white MS patients. These observations suggest that men and black patients with MS may have a more aggressive disease. The possibility that delays in MS evaluation or MS diagnosis in these populations could contribute to worsened outcomes remains underexplored.

Objectives

To evaluate whether sex or race may be associated with delays in being evaluated for possible MS or in being diagnosed with MS.

Methods

We surveyed patients with a confirmed diagnosis of MS at our center in the Washington, DC region from November 2019 to March 2020, asking them to recall three events: their initial symptom onset, their first neurology visit, and their eventual MS diagnosis.

Results

Out of 101 total surveys, 94 (93.1%) were included in this analysis. 72.3% of respondents were women. Most respondents self-identified as black (N=49, 52.1%) or white (N=45, 47.9%). While there was no difference in age at symptom onset, men tended to be older than women at first neurology visit and at MS diagnosis (mean 35.9 vs 33.8 years and 39.8 vs 35.0 years, respectively). There was a trend towards longer median time from symptom onset to first neurology visit, and from first neurology visit to MS diagnosis for men (7.5 months and 2.5 months, respectively) vs. women (1 month and 1 month, respectively). The overall time from symptom onset to MS diagnosis was significantly increased for men compared to women with MS (21 months vs. 5.5 months, p=0.03). Black patients were more likely to have impaired gait at time of diagnosis than white patients (48.9% vs 28.6%, p=0.04), but there was also a trend towards longer median time from symptom onset to first neurology visit, from first neurology visit to MS diagnosis, and from symptom onset to MS diagnosis in black patients (2 months, 2 months, and 12 months, respectively) vs. white patients (1 month, 1 month, and 7 months, respectively). Black men in particular had longer median times from symptom onset to first neurology visit (12 months) and from first neurology visit to MS diagnosis (6.5 months) than other patient groups: black women (2 months and 1 month, respectively), white men (4.5 months and 1 month, respectively), and white women (1 month and 1 month, respectively).

Conclusions

There may be delays before men and black patients are evaluated for MS and before they are diagnosed with MS, compared to women and white patients. These delays in assessment and diagnosis could theoretically contribute to the observed poorer prognosis for patients of those at-risk populations.

Background

Designing data collection methods is a vital, yet challenging part of conducting multiple sclerosis (MS) clinical studies. Emerging technologies, such as wearable activity monitors (i.e. Accelerometers) and mobile applications (apps), provide innovative methods of objectively measuring MS patient outcomes. However, there is a gap in scientific knowledge about MS patients’ experiences with using these technologies in clinical research. This knowledge is imperative because patients’ perceptions of these technologies can affect adherence to study protocols. Research is needed to understand the feasibility of using these technologies for continuous long-term monitoring and data collection.

Objectives

To describe how persons living with MS perceived an accelerometer and diet-tracking app in a longitudinal clinical study and to apply this knowledge to the design and conduct of future clinical research.

Methods

This was a qualitative study nested in a larger observational study, which collected data using the Actigraph accelerometer and Calorie-Mama AI mobile app. Semi-structured qualitative interviews were conducted during final study visits (September 2018- March 2019), audio recorded, and transcribed verbatim. We continued interviewing participants until data saturation occurred. Qualitative data were analyzed using the constant comparative method. To further explore qualitative results, we did chi-squared tests to examine relationships between 1. age and successful diet tracking and 2. disability and interest in an MS self-management app.

Results

We interviewed 28 persons living with MS: 68% were female, mean age was 45.5 years, and median Expanded Disability Status Score (EDSS) was 2 (indicating low disability). Participants’ perceptions of the accelerometer were that it was “bulky” (n=21) and attracted unwanted attention (n=9), and that the band was uncomfortable (n=20). Participants (n=12) also mentioned they would have liked feedback from the device during or after the study. Despite stated issues, 93% of participants indicated they would use the device again in future studies. The mobile app was perceived as difficult to use to accurately track food (n=21) and time-consuming (n=10). As a result, half of participants did not correctly record their diet for the study. Younger age was associated with successful app use [X² (1, N=27)= 4.46, p=0.035]. Also, many persons living with MS were interested in an MS self-management app, and interest was associated with higher EDSS [X² (1, N=27)= 6.01, p=0.022].

Conclusions

Although participants had negative perceptions of the accelerometer, they were willing to use it for future studies, suggesting only minor design modifications may be needed. Mobile apps also should be easy to navigate and use, especially among older persons living with MS. A surprising finding was that MS mobile apps may be more appealing to younger persons living with MS who have greater disability.

Background

Detailed updated records from Multiple Sclerosis (MS) patient cohorts are crucial to obtain information on disease course and prognosis.

Objectives

To characterize the natural history of MS in a cohort from a Portuguese tertiary centre, comparing patients’ characteristics according to the first appointment date throughout 10-year spans (1987-1996; 1997-2006; 2007-2016).

Methods

In this longitudinal retrospective study we collected data about demography, diagnosis (date, EDSS, subtype), follow-up (duration, EDSS, subtype), relapses (initial symptoms, annualized relapse rate-ARR) and disease-modifying therapies (DMT). We conducted descriptive analysis to characterize the cohort and compared data between the three decades using Chi-square test, ANOVA and Kruskal-Wallis test.

Results

548 adult patients with relapsing-remitting MS were included, 73% female. Mean age at diagnosis was 34.0 years and mean disease duration 14.7 years. 5.7% of all patients had family history of MS. Eighteen patients had died. No significant differences were found regarding gender and age at diagnosis in patients from the 3 subgroups. The most common presenting relapses were supratentorial and spinal cord related. The median number of relapses between first and last appointment was 3, significantly higher in subgroups 87-96 and 97-06, although the ARR was significantly higher in the subgroup 07-16. The baseline EDSS was significantly higher in 87-96 decade and the percentage of patients achieving EDSS 3.0 and 6.0 significantly decreased since first decade. The mean time between EDSS 3.0 and 6.0 was 4.28 years, without significant differences in the 3 decades. The percentage of patients who converted to secondary progressive (SP) disease was significantly higher in 87-96 decade; the mean time to reach SP was 15.5 years, similar in all decades. The majority of patients started treatment with a first line DMT. The number of patients under a second line drug was higher for those included in the decades 97-06 and 07-16. Median time from diagnosis to first treatment was considerably higher for patients with first appointment in the 87-96 decade.

Conclusions

We document the natural history of MS in 3 decades, including 87-96 where DMT were not yet available, and found that patient’s demography remains similar. The higher ARR in last decade may reflect a better awareness of disease monitoring and differences in disability progression may be due to the impact of increasing DMTs.

Background

IgG4-related disease (IgG4-RD) is a multisystem disorder, which can affect nearly every organ system. Although involvement of the nervous system is commonly described, systematic descriptions of neurological involvement are rare.

Objectives

Our objective was to describe the characteristics of patients diagnosed with IgG4-RD presenting with neurologic involvement.

Methods

Patients with IgG4-RD were retrospectively identified by screening medical records of all patients, who had signed general consent, treated at the outpatient neurology clinic of our university hospital.

Results

Since 2012, we found 12 cases of IgG4-RD of whom eight cases presented with neurologic manifestations. Of those 6/8 (75%) patients were male. Mean age at symptom onset was 62 years (range: 35 - 81 years). In 2/8 (25%) of patients, neurologic presentation was the only disease manifestation and consisted of pachymeningitis, cranial neuropathy affecting cranial nerves II, V and VII, peripheral neuropathy, myalgia, carotid stenosis and cerebral ischemia. Lumbar puncture was performed in 5/8 (62%) patients and showed elevated cell count in 1 patient (range: 2- 9 M/l). Mean serum IgG4 concentration was 4.58 g/l (range 1.35 - 12.3 g/l) and was elevated in 7/8 patients. In the patient with normal IgG4 values biopsy was compatible with IgG4-RD. Total serum IgG was elevated in 4/8 (50%) patients with a mean of 14.9 g/l (range 8.92 – 21.6 g/l). Immunotherapy was started in 7/8 (87%) patients. Three patients received a high dose steroid monotherapy; other treatments were rituximab, methotrexate and leflunomide. Under these therapies, the outcome was favorable in 4/8 (50%) of patients, 3/8 (38%) remained unchanged and one patient succumbed to an unrelated pathology (colorectal cancer).

Conclusions

IgG4-related neurologic disease can manifest with multisystem involvement, but isolated neurologic manifestation is possible. If diagnosis is considered in patients with normal IgG4 levels biopsy should be obtained.

Background

Glutamic Acid Decarboxylase (GAD65) antibodies may be asymptomatic or associated with a variety of neurological manifestations. It is frequently associated with Type 1 diabetes.

Objectives

The main objective is to determine the clinical characteristics and treatments used for patients with GAD-65 antibodies.

Methods

This was an observational, retrospective, single-center study enrolling all patients found to be positive for GAD65 antibodies between January 2010 and December 2019. To select for cases thought to have neurologic manifestations of GAD65 autoantibodies, we further selected for subjects who were evaluated and assessed by the neurology service.

Results

1015 patients tested positive for GAD65 autoantibodies, but only 123 (12.1%) patients were evaluated by the neurology service. Among the subset evaluated by Neurology, the mean age was 47.1 (±20.8) and 67 (54.5%) were female. Diabetes mellitus (DM) was seen in 60 (48.8%) of the cases. The most common neurological manifestation was as follows: seizure 32 (26%), stiff-person syndrome 30 (24.4%), encephalitis 17 (13.8%), ataxia 16 (13%) and nystagmus 6 (4.9%). Thirty nine (31.7%) patients were diagnosed with peripheral neuropathy, which was likely secondary to DM in most cases. Seizure and stiffness were observed more frequently in females, although this was not a statistically significant difference.

Abnormal MRI brain was seen in 60 (48.8%) of the cases. Patient were treated with: intravenous steroid 45 (36.6%), oral steroid 59 (48%), intravenous immunoglobulin 58 (47.2%), plasmapheresis 14 (11.4%), rituximab 25 (20.3%), azathioprine 15 (12.2%), mycophenolate mofetil 12 (9.8%) and cyclophosphamide 6 (4.9%).

Conclusions

At least one tenth of GAD-65 antibody positive cases needed a neurological evaluation. The most common clinical presentations in our cohort were seizures and stiff-person syndrome.

Background

Ocrelizumab is one of the most effective disease-modifying drugs for MS. As a potent immunosuppressor, ocrelizumab carries significant infection risk and its long-term effects on immunocompetence are not fully understood. Although ocrelizumab is given as a regular six-monthly infusion, it shares several characteristics with immune reconstitution therapies, such as alemtuzumab and cladribine. Alemtuzumab and cladribine deplete circulating lymphocytes and ocrelizumab specifically depletes circulating B-cells, with reconstitution of cells occurring from bone marrow. It is not known whether the therapeutic effect of ocrelizumab outlasts the administration period. Giving ocrelizumab in a time-limited fashion could reduce both short- and long-term side effects, as well as provide a substantial cost reduction.

Objectives

Share experience of a case in order to stimulate investigation into ocrelizumab as an immune reconstitution therapy.

Methods

1. Consent was successfully obtained to present the patient's case.

2. Case details were collated, including radiological and laboratory data.

Results

A 24-year-old female patient was diagnosed with MS following subacute onset left hemiparesis, positive CSF oligoclonal bands, exclusion of mimics and MRI showing multiple T2 lesions in the periventricular areas, corpus callosum and juxtacortical areas. Her baseline MRI performed immediately prior to treatment commencement showed five new T2 lesions with new enhancement. She was treated with five doses of ocrelizumab at six-monthly intervals between 2012-14 as part of a clinical trial. She then decided to withdraw from the study to travel, but returned to the UK in 2020. Despite cessation of all disease modifying treatment for six years the patient reported no clinical relapses, and in comparison with the MRI at treatment cessation in 2014 there were no new lesions or enhancement. Lymphocyte subset analysis showed reconstitution of B-cells (578 x 10⁶ cells/L; normal range 50-500 x 10⁶ cells/L). The patient is fit and well and suffered no side effects of treatment.

Conclusions

A patient treated early with a limited course of ocrelizumab for two years demonstrated no evidence of disease activity (NEDA2) after six years without treatment. Caution is recommended in extrapolation from a single case, however investigation of ocrelizumab as an immune reconstitution therapy is warranted. Limited duration ocrelizumab treatment could have substantial benefits in terms of side effects, cost and patient convenience whilst maintaining efficacy.

Background

Previous studies showed that olfactory dysfunction was more common in patients with multiple sclerosis (MS) than in healthy individuals and correlated with neurological deficit and cognitive disturbances. However, most studies required the use of time-consuming olfaction examination.

Objectives

The aim of this study was to assess olfactory function in patients with relapsing-remitting MS (RRMS) and its possible correlation with inflammatory and neurodegenerative features of the disease with the use of short and simple screening olfactory test.

Methods

The study included 30 controls and 30 patients with RRMS matched for age and gender, all of Caucasian origin. Patients with RRMS were treated with disease modifying therapies (DMT) – 18 with injectables (interferon beta or glatiramer acetate) and 12 with oral drugs (dimethyl fumarate or fingolimod). Olfactory function was assessed with the Sniffin’ Sticks Identification Test (SSIT) comprising 8 pens with different scents. The score of 6 or less points was defined as hyposmia. The data concerning number of previous relapses, disability in Expanded Disability Status Scale (EDSS) and new T2 or gadolinium enhancing brain MRI lesions were collected from each patient. Cognition and fatigue in patients were evaluated with Symbol Digit Modalities Test (SDMT) and Fatigue Scale for Motor and Cognitive Functions (FSMC), respectively. Moreover, the volume of thalami and the width of the third ventricle on brain MRI were recorded in every patient.

Results

Patients with RRMS had nearly two-fold higher risk of hyposmia (odds ratio, OR=1.82, 95%CI: 1.10–3.67, p=0.02). The SSIT score did not correlate with disease duration (r=0.28, p=0.13), the length of DMT use (r=0.05, p=0.78) and the number of previous DMTs (r=0.26, p=0.17). Neither inflammatory (number of previous relapses, number of new T2 or gadolinium enhancing lesions on recent brain MRI) nor neurodegenerative (EDSS score and its progression, SDMT and FSMC scores, volume of thalami and the width of the third ventricle on MRI) MS features did not show any correlation with SSIT score (p>0.05). Hyposmia also did not correlate with new disease activity within the next 12 months after olfactory evaluation in relation to new clinical relapses (r=0.20, p=0.28) and new T2 (r=0.17, p=0.36) or gadolinium enhancing brain MRI lesions (r=-0.07, p=0.71). In the subgroup of patients treated with oral DMTs olfactory dysfunction strongly correlated with FSMC score (r=-0.90, p=0.006), mainly with its cognitive subscale (r=-0.90, p=0.006). Such correlation was not observed for patients receiving injectables.

Conclusions

Olfactory dysfunction is common in RRMS and correlates with the level of fatigue in cognitive functions in patients treated with dimethyl fumarate or fingolimod.

Background

Teriflunomide is a disease-modifying immunomodulatory drug with anti-inflammatory properties that selectively and reversibly inhibits the mitochondrial enzyme dihydro-orotate dehydrogenase, with consequent inhibition of de novo pyrimidine synthesis and reduced lymphocyte proliferation. Oral teriflunomide is approved by EMA for the treatment of adult patients with Relapsing-Remitting Multiple Sclerosis (RRMS).

Objectives

The purpose of our review was to assess for the first time the real-life efficacy, safety, and retention of Teriflunomide (TER) in Cypriot patients with RRMS, and to compare our results with those of other studies performed in similar populations.

Methods

Twenty-four adult patients were assessed retrospectively one year after the initiation of TER. Four patients (17%) received TER as the first Disease-Modifying Treatment (DMT), whereas twenty patients (83%) were converted to TER from other DMTs.

Results

At TER initiation, patients were of a mean age of 44 years (range: 21-63) and had a mean MS duration of 14 years (range: 0.5-30).

In treatment-naïve patients, mean Annual Relapse Rate (ARR) during the year before TER treatment was 0.5 (range: 0-1) and mean EDSS progression 0.5 (range: 0-1.5). Twelve months after TER, mean ARR remained stable (p=0.423) whereas EDSS progression was reduced by 25% (p=0.057).

In DMT-converted patients, mean Annual Relapse Rate (ARR) during the year before TER treatment was 0.4 (range: 0-3) and mean EDSS progression 0.3 (range: 0-1.5). Twelve months after TER, both mean ARR and EDSS progression remained stable (p= 0.111 and p= 0.241 respectively).

TER retention rate was 79%. Five patients (21 %) discontinued TER: Three due to disease progression, one due to extreme neck pain and one due to lactose intolerance.

Most frequent ADRs were infections (26% of patients), increased ALT (21% of patients) and gastrointestinal discomfort (21% of patients).

Conclusions

Teriflunomide proved to be equally effective to previously used DMTs in our DMT-converted patients, whereas it significantly reduced disease progression in our treatment-naïve patients. ADRs were mostly mild and transient leading to high retention to therapy.

Our results are in line with those of other studies demonstrating the efficacy, safety, and retention of Teriflunomide in similar populations.

Background

Effective treatment of relapse is critical for minimizing disability in patients with multiple sclerosis (MS). Repository corticotropin injection (RCI, Mallinckrodt Pharmaceuticals) is approved by the US Food and Drug Administration for treatment of MS exacerbations.

Objectives

This multicenter, prospective, observational, registry study aimed to characterize treatment patterns, recovery, and safety outcomes from patients receiving RCI for acute MS relapse.

Methods

Subjects were recruited before initiation of RCI for an MS exacerbation. Clinician assessments included the Expanded Disability Status Scale (EDSS), Functional System Score (FSS), and Clinical Global Impression of Improvement scale (CGI-I). Patient-reported outcome questionnaires included the MS Impact Scale (MSIS-29v1), Work Productivity and Activity Impairment: MS (WPAI:MS), and Health Resource Utilization (HRU). Safety was assessed by adverse events (AEs).

Results

In all, 125 subjects received ≥1 dose of RCI. Mean scores significantly decreased from baseline to month 6 for the EDSS (–0.45, n=56) and total (sum of all subsystem domain scores) FSS (–1.55; n=56) (p<0.0001 for both) with RCI treatment. The CGI-I also indicated statistically significant improvement at 6 months (p<0.0001). Mean MSIS-29v1 physical subscale scores decreased from baseline to month 2 (–7.99, p=0.0002, n=69, primary endpoint) and month 6 (–9.64, p<0.0001, n=48). For the WPAI:MS, mean changes from baseline to month 6 were statistically significant for percent work time missed due to MS (–27.75, p=0.0255, n=17) and percent activity impairment due to MS (–11.52, p=0.0003, n=46). Regarding HRU measures, the mean number of MS-related emergency department visits, hospitalizations, numbers of days in the hospital, and outpatient visits (other than healthcare professional visits at home) decreased from baseline at month 6. Thirty-five subjects (28.0%) reported 83 AEs, the most common being MS relapse, urinary tract infection (UTI), nasopharyngitis, and peripheral edema. Eleven subjects (8.8%) reported 16 serious AEs, the most common being MS relapse, UTI, and asthenia.

Conclusions

Clinically meaningful improvements on the EDSS, CGI-I, and MSIS-29v1 physical subscale, along with statistically significant improvements in additional clinician- and patient-reported outcomes and the low incidence of serious AEs, support the efficacy and safety of RCI for the treatment of MS relapse.

Background

Diagnosis of secondary progressive multiple sclerosis (SPMS) patients and the identification of the transition phase from relapsing-remitting multiple sclerosis (RRMS) to SPMS remain a challenge as reliable clinical diagnostic criteria and diagnostic tools are lacking.

Objectives

This analysis evaluates disability parameters and patient reported outcomes in patients with RRMS at risk for SPMS and SPMS to:

– compare clinical parameters including magnetic resonance imaging (MRI), quality of life and socioeconomic aspects of patients with SPMS to patients at risk for SPMS

– characterize patients in the transition phase from RRMS to SPMS

– evaluate performance of the novel progression questionnaire (MSProDiscuss) in clinical routine

Methods

PANGAEA 2.0 EVOLUTION is part of the non-interventional real-world study PANGAEA 2.0 including approximately 2,500 RRMS patients. Additionally up to 1,000 patients diagnosed with SPMS or on risk for SPMS are currently being recruited and will be prospectively followed independently of treatment for up to 2 years. Diagnosis for risk for SPMS is made by the physician after a comprehensive evaluation of the patient's symptoms including for example relapses, fatigue, progression or impact on quality of life as there are no standard criteria for the transition state for RRMS to SPMS. Routine clinical measurements including EDSS, relapse rate, MRI and cognition measurements, quality of life (EQ-5D, MSIS-29) and socioeconomic conditions (MS-HRS, WPAI) as well as observational parameters from the physician’s perspective (UKNDS, CGI) are collected at 6-month intervals.

Results

Real world data of approximately 400 patients will be shown. Profiles of patients with different progression states will be compared and assessed for differences. MRI findings will be correlated with clinical and patient reported outcomes. Status of disease progression will be correlated with quality of life and socioeconomic measures collected within this study.

Conclusions

PANGAEA2.0 EVOLUTION allows to compare SPMS patient profiles with RRMS patients at risk for SPMS in a real world setting. By combining clinical and non-clinical parameters a clearer picture can be generated for the establishment of standard early diagnosis criteria and therapy of SPMS patients.

Background

Adherence to disease-modifying therapy (DMT) is critical for achieving therapeutic goals in multiple sclerosis (MS). Real-world evidence on persistence and adherence with ocrelizumab (OCR) is limited.

Objectives

This analysis aimed to examine the persistence and adherence to OCR compared with other MS DMTs.

Methods

This analysis was conducted in the PharMetrics Plus commercial claims database and included patients with MS who initiated a new DMT between April 2017 and September 2018. Patients were required to have health plan enrollment for ≥12 months before and after DMT initiation. Persistence and adherence were measured in patients with ≥12 months and ≥18 months of follow-up. Persistence was defined as no switch to other DMTs and no gap in supply of initiated DMT for ≥60 days. Adherence was assessed using the proportion of days covered (PDC), calculated as the total days of supply of DMT during the postinitiation period divided by either 365 days (12-month analysis) or 548 days (18-month analysis). Multivariable Poisson regression models were used to compare discontinuation of (nonpersistence) and nonadherence (PDC <0.80) with OCR vs oral, injectable, and other intravenous (IV) DMTs.

Results

A total of 4,587 (OCR, 1,319; injectable, 1,051; oral, 1,876; IV, 341) patients were included. At 12 months, patients initiating OCR had the highest mean PDC (93.4%) compared with other groups (injectable, 69%; oral, 74%; IV, 76%) and the highest proportion of patients persistent with therapy (92% vs 57%, 68% and 72%, respectively). Compared with OCR, adjusted relative risks of 12-month discontinuation (95% CI) were 5.5 (4.1–7.5), 3.8 (3.0–4.9) and 3.3 (2.3–4.6) in patients initiating injectable, oral and IV DMTs, respectively, and relative risks of nonadherence were 6.8 (5.0–9.3), 5.1 (3.9–6.6) and 4.9 (3.6–6.8), respectively. Among patients with 18 months of follow-up (n=2,319), 83% of OCR patients demonstrated persistence vs 45%, 59% and 60% of injectable, oral and IV patients, respectively. Trends in discontinuation and nonadherence for the DMT groups over 18 months were consistent with 12-month results in fully adjusted models.

Conclusions

Patients initiating ocrelizumab had superior persistence and adherence at both 12 and 18 months of follow-up compared with other groups of MS DMTs. Long-term persistence and adherence should be monitored as ocrelizumab experience accrues in a real-world setting.

Background

Multiple Sclerosis (MS) tipically affects young adults; however, the first symptoms can occur after age 50 and is classified as late-onset MS (LOMS). Previous population-based studies described a frequency that ranged from 2 to 10% of LOMS, however scarce information exists in our region regarding this aspect.

Objectives

The objective of the present study was to describe the frecuency and clinical aspects of LOMS patients included in the Argentinean MS and NMOSD registry (Relevar EM, NCT 03375177).

Methods

Relevar EM is a longitudinal, strictly observational MS and NMOSD registry in Argentina. The eligible study population and cohort selection included all patients with definite MS included in the registry at 31 December 2019. LOMS was defined in MS patients in which the first symptom of disease was identified after the age of 50 years. Clinical and demographic aspects of the disease was described. Prevalence rate of LOMS and 95% CI was calculated.

Results

We included 2408 MS patients, mean age 42 (SD 8) years, 65.5% female. LOMS was identified 191 patients, prevalence rate 7.9%, 95% CI 6.85-9.01. In LOMS patients, 141 (68.5%) were female, mean age at disease onset 55 (SD 3.5) years. The mean EDSS was 3.5 (range 2-6). The most frequent first symptoms were motors deficits (33%) and multisystem deficits (33%). Most frequent clinical course (in all the cases with a minimal disease follow up of 3 years after the onset) was the relapsing remitting-MS (54.5%) fenotype. Primary progressive-MS in LOMS was observed in 20.9%. Oligoclonal IgG bands were positive in the 72 % of patients in the CSF study.

Conclusions

In our study we found a prevalence of LOMS of almost 8%. Most patients were RRMS. The frequency found in our cohort is like other population- based studies performed in Europe

Background

Rabies is a rapidly progressive neurodegenerative infection caused by rabies lyssavirus, which infects animals worldwide. The incubation period can vary from weeks to several months, but once clinical symptoms become apparent, rabies is almost always fatal. The first rabies vaccines (RV) were made from the spinal cords or brains of rabies-infected animals. Their high concentrations of myelin caused various neurological adverse events including acute disseminated encephalomyelitis (ADEM). Current RVs are deemed considerably more tolerable and highly effective. To date, no studies of RV tolerability in MS have been conducted. In an effort to begin filling this knowledge gap, we report the safety data on rabies vaccine (RV) in multiple sclerosis (MS) patients outcomes of 55 MS patients who underwent rabies vaccination at our center in recent years.

Objectives

The primary outcome was the relative incidence of MS relapse in the ERP versus that of the PEP. Other outcomes include i) new brain and/or spinal cord lesions found on T1-weighted, gadolinium-enhanced or T2-weighted magnetic resonance imaging during the three study periods and ii) potential risk factors for relapse (n=3) in the exposure-risk period versus no relapse (n=52).

Methods

In this single-center, self-controlled retrospective cohort study, the 12 months preceding RV administration were defined as the pre-exposure risk period (PEP), the three months thereafter as the exposure-risk period (ERP), and the following nine months as the post-risk period (PRP). The primary outcome was the relative incidence of MS relapse in the ERP versus that of the PEP.

Results

Fifty-five patients received RV; 21 (38%) experienced 24 PEP relapses. Three (5%) experienced three ERP relapses; three other patients experienced four PRP relapses.

Conclusions

In this cohort of 55 MS patients undergoing rabies vaccination, we could not identify any risk for relapse in the year following vaccination, even among those who received up to seven repeated doses of RV. We also show that immunosuppression at the time of rabies vaccination was not a risk factor for vaccine-related complications.

Background

Teriflunomide is an oral formulation which was approved as first line option for the treatment of Relapsing-Remitent Multiple Sclerosis. Its efficacy and adverse events have been described in randomized controlled trials. Data for regular clinical practice are need. We have been using teriflunomide since july 2015.

Objectives

Our objetive is to describe our initial experience with Teriflunomide in terms of tolerance and clinical effectiveness after 3 years of treatment.

Methods

All patients from 10 Clinical Hospitals in Galicia, Spain, who were prescribed Teriflunomide were included, regardless of time on treatment. Basics demographic, clinical data, disability (EDSS scale), number of relapses, number of GD enhancing lesions on craneal MRI, adverse events and reasons for discontinuation under teriflunomide were reported.

Results

378 patients (70.6% woman) were reviewed, 41.5% naive, average age 44.9 years old (±9.7), average anual relapse 0.64 (±0.7), average EDSS 1.8 (±1.5), average number Gd enhancing lesions 0.58 (±1.3). 295, 182 and 90 patients complied 1, 2, 3 years of treatment, respectively. Teriflunomide decrease average anual relapse 0.41(±0.0), 0.43(±0.0) and 0.47(±0.0) p<0,05 at 1, 2, 3 year, disability was worst 1.9 (±1.6), 2.0 (±1.8) and 2.6 (±1.8) p<0.05 at 1, 2, 3 year, average number Gd enhanging lesions was 0.23 (±0,6), 0.20 (±0,8) and 0.15 (±0.5) p<0,05, at 1, 2, 3 year. 135 (45.7%), 50 (27.4%) and 21 (23.3%) experience adverse events at 1, 2, 3 year, most common hair thinning (15.5%), gastrointestinal (13.8%), elevation ALT (8.1%) and headache (5.7%). 3 severe adverse event (elevation ALT, myocardial infarction, breast carcinoma). 33, 26 and 22 patients stopped the treatment in the 1, 2, 3 year, 50% inneficacy.

Conclusions

The efficacy of teriflunomide in real-life setting was demostrate by the stability in reduce the number of relapses, although dissability was mild worsten. Teriflunomide has been well tolerated by the majority of patients.

Background

Background:Disability accumulation can result from progression independent of relapsing activity (PIRA) even during the RR phase.

Objectives

Aims: We assessed the contribution of PIRA to the development of permanent disability, among RRMS treated with Alemtuzumab(ATZ).

Methods

Methods: retrospective data from 147 RRMS patients, who received ATZ at Imperial College Healthcare Trust, followed up for 3 mean years. PIRA was defined as 1.5point increase of EDSS if baseline EDSS was 0, 1point increase if baseline EDSS was <5.5, or 0.5point increase if baseline EDSS was >= 5.5,90days from the previous relapse. The logistic regression analysis was used to assess factors affecting the risk of PIRA.

Results

Results In the whole group female predominated (60%), 19% were treatment naïve and 81% were escalated to ATZ from previous DMTs; 15% (n = 23) received one course of ATZ only. At first ATZ infusion, the mean age was 42 years, the mean disease duration was 8 years and the mean EDSS score was 4. During the observation period, the EDSS remained stable in 58% (n=84) or improved in 11% (n = 17), while it worsened by 1.5 mean point (min 0.5 max 4.5) in 31% (n = 46). Among patients who experienced EDSS worsening, disability accumulation was related to PIRA in 76% (n = 35), while in only a minority (n = 11) it resulted from relapse-associated worsening. Compared to the whole group, patients with PIRA had at first ATZ infusion same mean EDSS score (4, p =0.8), but they had longer disease duration (11 versus 7 mean years, p=0.007), were significantly older both at disease onset (36 vs 32 mean years, p=0.046) and at commencement of the therapy (47 vs 40 mean years, p=0.001). In addition, in the PIRA group vast majority (94%) of patients were escalated to ATZ after lack of response to previous DMTs. The logistic regression analysis confirmed that older age at first ATZ course (OR 6.7, p=0.037) and being escalated to ATZ from previous DMTs (OR 1.1, p= 0.002) are factors significantly associated with higher risk of PIRA.

Conclusions

Conclusions We confirmed in the real-world setting that in a large proportion of patients the disability accumulation can occur despite effective therapeutic relapse suppression. Older patients receiving ATZ as escalation therapy are more likely to experience PIRA.

Background

Seropositive autoimmune encephalitis is a heterogeneous and rapidly expanding diagnostic category with variable presentations and treatment responsivity.

Objectives

To determine the distribution, clinical characteristics, responses to treatment and clinical outcomes for real-world cases of confirmed seropositive autoimmune encephalitis.

Methods

Patients within a single, tertiary medical center identified to have positive blood or CSF autoantibodies on panels sent to Mayo Laboratories between January 2010 and December 2019 were identified and retrospective chart reviews were performed. Patient with low antibody titers and clinical features not suggestive of an autoimmune syndrome were excluded.

Results

1858 patients were tested for autoimmune encephalitis antibody panel. Two hundred nineteen (11.79%) had positive autoantibodies but only 42 cases fulfilled the inclusion criteria. The mean age of the patients was 53.4 (± 21.4) with 71.4% female predominance. The majority of the patients presented with altered mental status (n=15, 35.7%) or new onset seizure (n=13, 30.9%).The most common autoantibodies detected were anti NMDA (n=12, 28.6%) followed by anti LGI (n=11, 26.2%) and anti-neuronal nuclear antibody (ANNA, or anti-Hu, n=9, 21.4%). The most common treatments used were steroids (n=37, 88.1%) and IVIg (n=31, 73.8%). Rituximab was the most common second line treatment (n=20, 47.6%). The worst clinical outcomes were seen with ANNA-associated syndromes; these patients had a mean modified Rankin score of 5.8(± 0.3). Six of these patients had a small cell lung cancer. Patients with NMDA and LGI autoantibodies had a better response to treatment with mean mRS of 1.8 (± 1.03) and 1.5 (± 1.36) respectively.

Conclusions

Anti-NMDA and LGI were the most commonly detected autoantibodies in our cohort and also had the best clinical outcomes. Patient with ANNA had the worst clinical outcomes and small cell lung cancer was the most common associated malignancy.

Background

An estimated 240000 people in Germany are living with relapsing multiple sclerosis (RMS), which substantially impacts quality of life. Injectable, infusion and oral disease-modifying therapies (DMTs) are available for treatment; some of the most commonly used first-line DMTs in Germany are glatiramer acetate (GA) including follow-on GA (FOGA), dimethyl fumarate (DMF) and teriflunomide (TER). Little is known about current comparative patient characteristics and outcomes associated with injectable or oral DMTs in the real world.

Objectives

Describe patient demographics, clinical characteristics and treatment patterns (switching/discontinuation) among RMS patients on commonly prescribed DMTs.

Methods

This was a retrospective claims database analysis using data from the Institute for Applied Health Research Berlin database. International Classification of Diseases and Anatomical Therapeutic Chemical Classification system codes were used to identify RMS patients, in the index period 1 Jan 2016 to 31 Dec 2018. Patients were eligible if they had: ≥1 inpatient RMS diagnosis and/or ≥2 outpatient or ≥1 outpatient diagnosis and a DMT prescription in the enrolment period. Patients were naïve for the respective DMT, defined by a 12-month prescription-free period (pre-initiation).

Results

Of 16283 patients with RMS; 1577 patients met all inclusion criteria (GA, n=575; FOGA, n=24; DMF, n=608; TER, n=370). The FOGA group was too small for further analyses. Patients in the TER group were older and had a higher proportion of comorbid hypertension, depression and antidepressant use versus other groups. No other substantial demographic differences were observed. Pre-index mean (standard deviation [SD]) annual overall relapse rate (ORR) was 1.18 (1.19) for GA, 1.18 (1.20) for DMF and 0.99 (1.28) for TER; post-index mean (SD) ORR (12 months post-initiation) was 1.05 (1.56) for GA, 1.00 (1.53) for DMF and 0.86 (1.43) TER. 12 months post-initiation, DMT persistence was 45.9% for GA, 49.7% for DMF and 54.6% for TER; switch rates were 21.0% for GA, 17.4% for DMF and 14.1% for TER.

Conclusions

RMS patients prescribed GA and DMF were generally comparable in demographics, measures of disease activity, and treatment persistence. Despite different administration methods and mechanisms of action, similar ORR and treatment persistence were observed. In contrast, patients prescribed TER were numerically older and exhibited more comorbidities and lower pre-/post-treatment ORR.

Background

Ocrelizumab was approved in March 2017 for the treatment of relapsing or primary progressive MS. Despite the abundance of information concerning the efficacy and safety of ocrelizumab in phase III clinical trials, there is scarce evidence regarding real world patient profiles

Objectives

The aim of this study was to evaluate patient profiles, effectiveness and persistence to treatment in patients who used ocrelizumab for the treatment of multiple sclerosis (MS) in Latin America (LATAM)

Methods

retrospective multicenter study in Argentina, Chile and Mexico. Medical record databases of patients who received ocrelizumab and were followed for at least 1 year before and after treatment initiation were analyzed. Demographic and clinical variables were described as well as the effectiveness outcomes that included the proportion of patients free from clinical relapses, from disability progression, from new or enlarging T2 or T1 gadolinium-enhancing lesions on annual MRI. The proportion of patients discontinuing the treatment and the reason were registered.

Results

A total of 81 patients were included. The most frequent phenotype was relapsing remitting MS in 64.2% of patients. The mean age at study entry was 41.3 ± 12 years and 51.8 % were women. A total of 38% had relapse activity during the previous 12 months of ocrelizumab initiation, with a mean relapse rate of 1.3 ±0.6 during that period. 75 % were free from clinical relapses and 91% were free from gadolinium enhancing lesions in RRMS. Ocrelizumab discontinuation during the first 12 months was observed in 3 patients (3.7%). The mean persistence observed during the first year follow up was 338 ± 24 days.

Conclusions

Our study is in line with previous randomized clinical trials and recent real-world studies describing patient profiles effectiveness and persistence to ocrelizumab treatment in MS patients in LATAM.

Background

Ocrelizumab is a humanized monoclonal antibody against CD20 positive B-lymphocytes, which has been approved for relapsing-remitting and primary progressive forms of multiple sclerosis (MS) since March 2017.

Objectives

To provide real-world experience on patients with MS treated with ocrelizumab in our center along with safety and efficacy across different ethnic groups not studied in clinical trials.

Methods

This is a retrospective observational analysis of MS patients treated with Ocrelizumab from March 31^st, 2017 to April 30th, 2020. We collected data from patients who had received at least one infusion of ocrelizumab at our MS center. Patient characteristics, including demographics, clinical disease course, documented side effects, were collected and analyzed.

Results

A total of 82 patients were eligible for this study, of which 72% were relapsing-remitting MS, mean disease duration was 7.6 years, 14% had primary progressive MS, duration of 3.5 years, and 11% active/relapsing secondary progressive MS patients with a duration of 17.8 years. 22% of our patients were from African American descent, 61% Caucasian, and 17% from Hispanic descent, which is different from the clinical trial population. Mean age at starting ocrelizumab was 41 + 11. 47% were treatment naïve when they were started on ocrelizumab, 24% treated with 1 DMT, 14% treated with 2 DMTs, 15% treated with >2 DMTs before ocrelizumab. 50% of patients had at least one adverse event on ocrelizumab, 4.8% had adverse events leading to discontinuation of ocrelizumab, 36% had infusion-related reactions, 7.3% had viral infections, we report one case of babesiosis, re-activation of lichen planus, agranulocytosis, severe lymphopenia, ectopic pregnancy. There was no malignancy, progressive multifocal leukoencephalopathy (PML) or death in our patient population. The mean duration on ocrelizumab was 17.3 months in the RRMS group, 28.2 months in SPMS, 22.2 months in the PPMS group. Annualized relapse rate reduced from 1.33 to 0.015 in the RRMS group while on ocrelizumab, median extended disability status scale (EDSS) scores remained stable across MS phenotypes and ethnicity groups

Conclusions

In a diverse patient population ocrelizumab was well tolerated without significant adverse events. There were index cases of babesiosis, re-activation of lichen planus, lymphopenia, agranulocytosis, and ectopic pregnancy. It is vital to consider geographic risk factors that may expose patients to babesia microti while in Ocrevus, since there are three additional cases reported to the FDA database and multiple cases with other anti-CD20 medications. No malignancy, PML or death was seen in our patient population. Ocrelizumab was effective with decreased relapse rate and stable EDSS scores across MS phenotypes as well as different ethnic groups. Our study extends the generalizability of the effectiveness of ocrelizumab from clinical trials to a real-world setting in a diverse population

Background

Cladribine tablets are approved for treatment of multiple sclerosis (MS) in many jurisdictions. Real-world outcomes data is very limited.

Objectives

We analysed the cladribine treatment experience in the MSBase registry. We described baseline characteristics, treatment pathways, and relapse and discontinuation outcomes in patients with ≥6 months follow-up data from cladribine initiation.

Methods

We performed a secondary data analysis using MSBase Registry data of patients with a confirmed diagnosis of MS and newly treated with cladribine tablets after regulatory approval. Descriptive statistics were used to analyze baseline patient characteristics recorded within 3 months prior to cladribine tablets initiation, including demographics, disease course and duration, prior disease modifying drugs (DMD), and Expanded Disability Status Scale (EDSS).

Results

As of the 4th June 2020, MSBase included 660 patients treated with cladribine from 9 countries, mainly from Australia and Europe. A total of 576 met all inclusion criteria. These included 496 relapsing-remitting MS (RRMS) patients. In these, median age at cladribine tablets start was 45 years and median disease duration since clinically isolated syndrome was 12.6 years. Median EDSS at cladribine tablets start was 2.5. Around 13% of all RRMS patients initiated cladribine tablets as first line therapy. Of all RRMS patients switching to cladribine tablets with a treatment gap of <6 months, the most common immediate prior DMDs were fingolimod (17%), followed by natalizumab, teriflunomide and dimethylfumarate (all appx. 10%). Total follow-up time was 340 patient-years. Annualised relapse rate (ARR) on cladribine tablets was 0.12 (95%CI 0.09-0.17), compared to a pre-cladribine ARR of 0.38. Treatment persistence was 95% after 12 months (95%CI 91-98%), and 92% after 24 months (95%CI 87-96%).

Conclusions

This study characterizes RRMS patients treated with cladribine tablets in a real-world clinic setting. First-line use was uncommon. ARR was low, consistent with clinical trial data, and early discontinuations were very rare.

Background

Ocrelizumab (OCR) is a humanized monoclonal antibody that targets CD20 positive lymphocytes, resulting in preferential B cell depletion. It is FDA approved for relapsing-remitting, primary progressive and secondary progressive multiple sclerosis (RRMS, PPMS and SPMS).Ocrelizumab (OCR) is a humanized monoclonal antibody that targets CD20 positive lymphocytes, resulting in preferential B cell depletion. It is FDA approved for relapsing-remitting, primary progressive and secondary progressive multiple sclerosis (RRMS, PPMS and SPMS).

Objectives

We present a real-world safety and efficacy analysis of ocrelizumab therapy in a comprehensive multiple sclerosis center.

Methods

A query to Genentech’s MyPatientSolutions for patients prescribed and treated with OCR through the University of Florida’s MS Center between March 2017 and June 2020 produced a sample of 163 patients. Data was captured through electronic chart review, stored in REDCap, and exported to SPSS for statistical analysis.

Results

Patients had a mean age of 48.1 years (range 22-73), were predominantly female (68.7%). Of the 163 patients, 66.2% had RRMS, 20.9% SPMS, and 12.9% PPMS. Infusion reactions (IR) were reported in 41 patients (25.1%), 11 of whom had recurrent IRs. At least one infection occurred in 42 patients (25.8%), with 20 (12.2%) experiencing recurrent infections. Urinary tract infection (UTI) was most commonly reported, followed by respiratory tract infection with women being more likely to have an infection (73.1%, p=0.016). Malignancies were reported in 4 patients (2.5%), 2 breast cancer, 1 pancreatic carcinoma, and 1 renal cell carcinoma. Eight patients (4.9%) discontinued OCR due to IR, infection risk and patient preference. Six patients (3.7%) had gadolinium enhancing MRI lesions. Five patients (3.1%) received intravenous corticosteroids for a clinical relapse. There were 7 deaths reported, 5 of whom were on OCR at time of death. The mean age at death was 69 years. Deaths were associated with malignancy (pancreatic and renal cell carcinoma), sepsis, sudden cardiac arrest (1 patient) and unclear cause in 2 patients.

At least one occurrence of lymphopenia was reported in 39 patients (23.9%), however, persistent grade III lymphopenia was only reported in 6 patients and 2 of these patients reported recurrent infections. Similarly, persistent hypogammaglobulinemia was reported in 6 patients and persistently suppressed IgM levels in 13 patients.

Conclusions

OCR was effective at reducing clinical and radiographic progression. Some safety concerns were found, a larger sample and longer-term follow-up is needed to corroborate findings.

Background

Ocrelizumab (OCR) is a humanised anti-CD20⁺ monoclonal antibody approved for the treatment of primary progressive multiple sclerosis (PPMS), and relapsing forms of MS, including both relapsing-remitting (RRMS) and secondary progressive MS (SPMS) with relapses.

Objectives

In a real-world setting, to describe 1) baseline characteristics of patients with MS treated with OCR, 2) treatment pathway across lines of therapy up to initiation of OCR, and 3) initial clinical experience in patients with ≥6 months follow-up data from OCR initiation.

Methods

Secondary data analysis using MSBase Registry data including patients with a confirmed diagnosis of MS and started OCR therapy within 3 months prior to or at time of MSBase eligible/initial visit. Descriptive statistics were used to analyze baseline patient characteristics' recorded within 3 months of OCR initiation, including demographics, disease course and duration, prior disease modifying therapies (DMT), and EDSS. Occurrence of relapse was analyzed in patients with ≥6 months follow-up data from OCR initiation.

Results

As of 4^th June 2020, MSBase included 2531 patients newly treated with OCR, of whom 1679 had an EDSS evaluation within 3 months of OCR start. There were 1185 patients with RRMS, 236 with SPMS, and 183 with PPMS. Median age at OCR initiation was 41.9 years, 49.5 years, to 50.1 years in RRMS, SPMS, and PPMS, respectively. Mean disease duration from symptom onset up to OCR initiation was longer in SPMS (19.7 years) than in RRMS (10.6 years) and PPMS (9.7 years). OCR was initiated as first line therapy in 17.5%, 5.5%, and 54.2% of RRMS, SPMS, and PPMS patients respectively. Most frequent previous DMT’s in RRMS were fingolimod (25.7%) and natalizumab (23.5%). 693 patients with RRMS had ≥6 months follow-up during OCR exposure. Of these, 643 remained relapse free (93%; 95% CI 86.0, 100.0) over a mean OCR exposure of 1.23 years. The annualized relapse rate (ARR) was 0.08 (95% CI 0.06-0.10), compared to an ARR of 0.85 in the 24 months pre-OCR start. In the overall cohort, treatment persistence at 12 and 24 months was 98.4% (95% CI: 97.3-9.1%) and 92.5% (95%CI 89-95%), respectively.

Conclusions

This study characterizes an international population of patients with RRMS, PPMS, and SPMS newly treated with OCR in a real-world clinical setting. First-line use was uncommon in RRMS and SPMS. During OCR treatment, ARR was below 0.1, and OCR discontinuations were very rare.

Background

Trials leading to Cladribine (CLD) approval for the treatment of Multiple Sclerosis (MS) were conducted over a decade ago: there is a need of proof of CLD efficacy and safety profile in the present MS therapeutic landscape.

Objectives

To evaluate CLD efficacy and safety profile in the current MS population, and to identify early predictors of response.

Methods

Before the drug was marketed under the national healthcare system, in Italy CLD was available through a Free Of Charge (FOC) program. We asked all participating MS centres to contribute to the present study, collecting demographic, clinical and MRI data of the patients who received CLD in the FOC program.

Results

56 MS centres participated to the study, for a total of 236 patients (71% F) (mean age: 39 + 11,5 years; mean disease duration: 10 + 8,5 years). Mean Annualized Relapse Rate (ARR) in the two years before CLD was 0,7 + 0,6; median baseline EDSS was 3 (quartiles 1,5-3,5; range 0-6,5). 53 patients (22,5%) were treatment naïve, 107 (45,3%) switched to CLD from first-line DMDs (for inefficacy), 76 (32,2%) switched to CLD from a second line therapy (33/76 for safety or loss of tolerability, 43/76 for inefficacy). Mean follow up was 12,2 + 5 months. 84,7% of the patients were relapse-free at follow-up. Mean ARR at follow-up was 0,2 + 0,6. Patients taking CLD as first therapy were less likely to experience a relapse (HR 0,6; 95% CI: 0,2-0,8; p = 0,04) while a higher baseline ARR was a predictor of clinical activity (HR 2,7, 95% CI: 1,4-5,6; p = 0,004). Median EDSS at follow up was 2 (quartiles 1-3,5). EDSS was stable in 73.7%, improved of at least 1 point in 21,6% and worsened of at least 1 point in 4,7% of the patients. 157/236 patients completed one year of follow up. Of these 92 (59,7%) reached No Evidence of Disease Activity (NEDA-3); NEDA-3 was achieved more frequently by naive patients (70%) than switchers from a first (57%) or a second line (50%) (HR 2,3; 95% CI: 1,01-5,3; p = 0,04). 33/236 patients reported at least one adverse event (AE), most frequently infections (15 cases); other AEs included gastrointestinal side effects, cutaneous rash, aphthous stomatitis and headache. Two severe AEs were reported (one pneumonia, one melanoma).

Conclusions

Even with the limitations of a retrospective study, our data confirm CLD safety and efficacy profile. Consistently with previous studies on patients with a first demyelinating event, CLD efficacy is maximized when used early in the course of MS.

Background

MS-CQI is the first multi-center improvement research collaborative to improve system-level performance and population health outcomes for people with MS. MS-CQI is a three year study (2018-2020) to evaluate system-level performance variation and improve population health outcomes in MS care. Four MS Centers are participating, following approximately 5,000 people with MS.

Objectives

To describe system-level variation in two important population health outcomes for people with MS based on Year 1 (baseline/pre-intervention) results from the MS-CQI study: (1) relapses (exacerbations); and (2) all-cause hospitalizations.

Methods

MS-CQI collects eleven clinical electronic health record (EHR) outcome measures from outpatient clinical encounters in participating MS centers longitudinally-- including MS relapses, and all-cause hospitalizations. We also collect demographic information and comorbidities. We used ANOVA, multiple regression, and maximum likelihood estimation methods for inferential analyses to assess for system level variation in outcomes.

Results

Four MS centers in the U.S. are participating: an urban academic center (n=1,000); a rural academic center (n=1,000); a rural community hospital (n=1,500); and an urban private practice (1,500), following a total N=5,000 persons with MS (PwMS). Univariate analyses found significant differences between sites for relapses, disease modifying therapy (DMT), MRI utilization, emergency department utilization, comorbidities, and all-cause hospitalizations. Center-specific proportions of PwMS with at least 1 relapse ranged 5-16.9%. Mean relapse rate varied significantly (p<0.01) across all centers. Two sites were below the MS-CQI average of 7% (3.3%, 6.3%) and two were above the average (8.5%, 10.3%). Controlling for individual factors and covariates, and using the highest volume center as the referent group, logistic regression analyses identified significant center level effects on relapses in Year 1, with comparator sites demonstrating ORs as high as 2.61 (95% CI: 1.8, 3.8). Similarly, significant site (system) level effects (with high performing center specified as the referent group) were found for all-cause hospitalizations- with comparator sites demonstrating odds ratios (ORs) ranging as high as 2.4 (95% CI: 1.34, 4.4).

Conclusions

Adjusted analyses of population level data from the MS-CQI study identified significant geographic system-level variation in MS relapses and all-cause hospitalizations, suggesting that system-level (small area geographic variation) factors are influencing population level outcomes for these outcomes. Findings suggest that continued study of system-level variation and improvement may be needed to optimize these outcomes for people with MS.

Background

A wash-out duration lasting >1–2 months between the majority of sequential disease-modifying therapies (DMTs) is associated with an increased risk of disease reactivation in Multiple Sclerosis (MS) patients.

Fingolimod (FTY) induces sequestration of lymphocytes in secondary lymphoid organs and the average lymphocyte recovery following discontinuation takes 1-2 months. It has been hypothesized that the therapeutic effects of subsequent cell-depleting agents may be compromised if lymphocyte recovery is still incomplete and that shorter wash-out periods do not affect the disease reactivation risk.

Objectives

To assess the risk of relapses following FTY discontinuation and the initiation of a B/T cell-depleting agent initiation in relation to the duration of wash-out between the drugs using data from the Italian MS Registry.

Methods

Patients who initiated alemtuzumab, rituximab, ocrelizumab or cladribine within six months of FTY discontinuation, and with a follow-up of at least six months, or until a relapse occurred, were included in the study. The risk of relapses was assessed in relation to different wash-out durations (<6, 6-11, 12-17 and >/=18 weeks) using a Poisson regression analysis (and reported as incidence rate ratio - IRR) and a Cox proportional hazards model including age, disease duration, relapses during FTY treatment, EDSS and reason for FTY discontinuation as covariates.

Results

Inclusion criteria were met by 329 patients (226F, 103M; mean age 41±10 years). Following a median wash-out period of 11 weeks [IQR: 6-16], 175 patients started alemtuzumab, 69 rituximab, 68 ocrelizumab and 17 cladribine. Ninety patients relapsed during the wash-out period and 72 during the subsequent cell-depleting therapy. During the cell-depleting treatment, IRR for a relapse was significantly greater in patients with a washout-period of 12-17 (IRR (95%CI): 2.4 (1,1-5,5); p=0.037) and >/=18 weeks (6.0 (2.8-12.7); p<0.001) compared to the reference period (<6 weeks).

The multivariable Cox analysis showed that the time to a relapse was significantly influenced by the occurrence of relapses during FTY treatment (HR (95%CI): 1.4 (1.2-1.7); p<0.001). Moreover, wash-out durations of 6-11, 12-17 and >/=18 weeks were associated with a higher risk of a relapse in comparison to wash-out durations shorter than 6 weeks (3.8 (1.1-13.2); p=0.037; 6.0 (1.7-21.9); p=0.006; 16.3 (4.8-56.3); p<0.001, respectively).

Conclusions

The risk of relapses during a cell-depleting therapy following a sequestering agent, namely FTY, increases progressively with the duration of wash-out, underlining the need of a short wash-out period also in this type of treatment sequence.

Background

Peginterferon beta-1a every 2 weeks is approved to treat relapsing forms of multiple sclerosis (MS). The 5-year phase 4 PLEGRIDY Observational Program (POP) study explores the real-world safety and effectiveness of peginterferon beta-1a.

Objectives

Report safety, pregnancy outcomes, and clinical effectiveness of peginterferon beta-1a in patients enrolled in POP.

Methods

POP is fully enrolled (n=1208) and ongoing in 128 sites across 14 countries. Data reflect the fourth interim data cut as of September 2019, with the exception of pregnancy outcomes, which are reported as of February 2020. Patients diagnosed <1 year prior to POP study consent and naive to MS disease-modifying therapies were considered newly diagnosed (ND); all others were considered non–newly diagnosed (NND).

Results

Analyses of safety and effectiveness included 1161 (ND, 289; NND, 872) patients and 1160 (ND, 289; NND, 871) patients, respectively. Baseline (BL) characteristics were generally similar between the subgroups, though ND patients were younger than NND patients, had less disability, had more relapses in the prior year, and had a shorter MS treatment duration. Flu-like symptoms (FLS) and injection-site reactions were reported in 51.6% and 37.4% of ND patients, respectively, and 43.8% and 41.4% of NND patients, respectively. Treatment-emergent serious adverse events (AEs) were reported in 5.9% of ND and 8.1% of NND patients. The overall incidence of treatment-emergent AEs was 66.8% in ND patients and 65.0% in NND patients. Of the 32 pregnancies reported, 28 had known outcomes, including 24 live births without congenital anomaly (85.7%), 3 spontaneous abortions (10.7%), and 1 elective termination (3.6%). Adjusted annualized relapse rates in ND and NND patients were 0.11 and 0.12, respectively, with 74.0% of ND and 81.5% of NND patients free of relapse at 3 years. From BL to 3 years, mean Expanded Disability Status Scale scores appeared stable in ND (1.4 [n=118] to 1.5 [n=76]) and NND patients (1.9 [n=297] to 2.1 [n=194]).

Conclusions

These data from POP show a safety profile consistent with clinical trials. ND patients were more likely to experience FLS than NND patients, indicating the importance of FLS mitigation and management in the ND population. The high proportion of relapse-free patients at 3 years in both subgroups indicates the efficacy of peginterferon beta-1a in treatment of relapsing MS, including in ND patients who may benefit from early treatment initiation.

The POP study is funded by Biogen. Biogen funded the analyses and writing support for this abstract. Writing support was provided by Ashfield Healthcare Communications (Middletown, CT, USA).

Background

Although phase 3 clinical trials have demonstrated the efficacy and safety of ocrelizumab in patients with multiple sclerosis, real-world data are scarce.

Objectives

The aim of this study was to describe the effectiveness and safety of ocrelizumab for primary progressive multiple sclerosis (PPMS) and relapsing multiple sclerosis (RMS) in a clinical practice setting.

Methods

In this retrospective observational study, we analyzed clinical and MRI data in all patients with PPMS and RMS who had received at least one infusion of ocrelizumab in two health areas in south-eastern Spain. The main inclusion criteria was a history of initiation of ocrelizumab. Patients involved in any ocrelizumab trial were excluded. No evidence of disease activity (NEDA) outcome was assessed in RMS patients who were followed for at least one year.

Results

The cohort included 71 patients (43 women) who had received ocrelizumab; 30% had PPMS and 70%, RMS. At baseline, patients’ mean age was 47.1 years in the PPMS group and 39.4 years in the RMS group, while the median EDSS was 3.0 and 2.5, respectively. Median follow-up was 12.6 months (range 2 to 32). The median number of treatment cycles was 3. Most patients remained free from clinical and MRI activity after ocrelizumab initiation. Baseline MRI showed T1 Gd-enhancing lesions in 58% of the patients; by the first MRI control at 4-6 months, all patients except one were free of T1 Gd-enhancing lesions (63/64, 98.4% P<0.001). The proportion of patients with NEDA was 93.3% in the group of RMS patients who were followed for at least one year. Only two patients (2.8%) discontinued ocrelizumab; one due to pregnancy and the other one because of lack of efficacy, but none did so due to safety issues. Ocrelizumab was generally well tolerated; the most common adverse events were infusion-related reactions and infections, none of which were serious.

Conclusions

Our data confirm the short-term effectiveness, tolerability, and safety of ocrelizumab in real-world clinical practice. Further studies are needed to assess patient outcomes with longer follow-up periods.

Background

As of April 2020, >160,000 patients with relapsing forms of multiple sclerosis (RMS) or primary progressive MS (PPMS) worldwide had started treatment with ocrelizumab (OCR), a humanized monoclonal antibody selectively targeting CD20⁺ B-cells.

Pivotal studies established the risk-benefit profile of OCR under controlled trial conditions.

Objectives

Real-world data are needed to further characterise the safety of OCR in clinical practice. Here we present 1-year, real-world safety data for patients receiving OCR.

Methods

CONFIDENCE (ML39632, EUPAS22951), a non-interventional, post-authorization safety study, aims to enrol 3,000 patients with RMS or PPMS newly treated (up to 30 days prior or 60 days after enrolment) with OCR and 1,500 patients newly treated with other selected DMTs according to label at ~250 German neurological practices. Each patient is followed for 7.5–10 years. Study visits, documented circa every 6 months, follow routine clinical practice. The primary outcome is the incidence and type of uncommon adverse events (AEs) (incidence of 0.1% to 1% [1 to 10 out of 1000 patients] or less). Statistical analyses are mainly descriptive and exploratory. Assessments of effectiveness (secondary objectives) are presented separately.

Results

As of 30 June 2020, 2,129 patients treated with OCR had been recruited. The interim analysis is expected to include approximately 559 OCR-treated patients, ~82% with RMS and ~18% with PPMS, with 1-year follow-up data (mean baseline age [SD], 45.5 [11.4] years; 64.4% female; mean baseline EDSS [SD] RMS 3.3 [1.9], PPMS 4.5 [1.7]). Preliminary data showed that ~63.0% of patients had ≥1 AE during OCR treatment; ~26.8% had treatment-related AEs (TRAEs). The most common AEs were infections and infestations (~31.5%), nervous system disorders (~14.7%), and general disorders and administration site conditions (~12.3%). The incidence of serious AEs was ~14.0%, most frequently infections and infestations (~3.6%; RMS, ~3.9% [n=18]; PPMS, ~1.9% [n=2]), nervous system disorders (~3.2%), and injury, poisoning and procedural complications (~2.1). The most frequent serious infections were urinary tract infections (~1.3% [n=7]) and pneumonia (~0.5% [n=3]). Seven patients overall (1.3%) had treatment-related serious infections.

Conclusions

The safety profile of OCR in this first interim analysis of the CONFIDENCE study, representing a real-world population currently treated with OCR in Germany, was consistent with controlled clinical trials.

Background

Sleep abnormalities are very common among patients with multiple sclerosis (MS) affecting approximately 60% of them but still remain under-recognized and inadequately addressed. Some common types of sleep disorders include insomnia, sleep-related movement disorders, sleep-related breathing disorders, and circadian rhythm disorders affecting MS populations.

In 25-35% of MS patients sleep interruptions are present, with sleep fragmentation, both in the macro and microstructure, and this condition may explain, in part, the presentation of fatigue.

Objectives

Correlate sleep-related disorders with the presence of fatigue and its severity in patients with relapsing-remitting MS (RRMS).

Methods

24 patients with RRMS were evaluated between March 1, 2018 and February 28, 2020.

Each patient underwent: Modified Fatigue Impact Scale, Insomnia Severity Index, STOP-BANG, Pittsburgh Sleep Quality Index and nocturnal polysomnography with oxygen saturation.

The data was analyzed using the Minitab® 15.1.20.0 package.

Results

24 patients were included; 75% female (3:1); mean age 36.3 years, (± 9); with mean 1.96 (± 0.8) years since diagnosis. 58% presented some alteration in sleep patterns, predominating awakenings and micro-awakenings fragmentation.

Regarding the presence of fatigue in patients with sleep disorders, it was observed that the ones with altered structure (micro-awakenings / awakenings or intervened wakefulness) have presented a considerably higher score on the fatigue scale. Patients with adequate structure presented a mean of 18.3 (± 15), while those who presented a fragmented structure due to awakenings and micro-awakenings presented a mean of 34.58 (± 23.74).

In relation to the sleep quality, a higher score was detected in patients considered as poor sleepers (mean 32.21 ± 21.95), compared to patients with adequate rest (mean 16.2 ± 13.77). The same occurs concerning insomnia, where a higher score on fatigue scale is detected in patients with moderate severity clinical insomnia (mean 49.5 ± 9.32) in relation to those without clinically significant insomnia (mean 20.42 ± 23.12).

Conclusions

The results suggest that sleep alterations are involved in fatigue clinical expression in RRMS patients, supporting the importance of exploring their presence in initial evaluation. In this way, we could improve not only sleep structure and quality, but also fatigue in our patients, improving their quality of life and quality years.

Background

Teriflunomide is an FDA approved medication for relapsing-remitting multiple sclerosis. The efficacy of teriflunomide in progressive multiple sclerosis is not well characterized.

Objectives

To explore the safety and efficacy profile of teriflunomide in patients diagnosed with progressive multiple sclerosis.

Methods

We conducted a single-center retrospective observational analysis of a progressive multiple sclerosis population, assessing safety and efficacy in patients treated at least one year with teriflunomide or glatiramer acetate. Sustained progression of expanded disability status scale (EDSS) and sustained worsening of timed 25-foot walk (T25FW) were compared using a cox proportional hazards model.

Results

Teriflunomide group (n=29) mean characteristics: age=58 years (SD±7.6), disease duration=16.7 years (SD±9.5), EDSS =5.9 (SD±1.3), follow-up=32.4 months (SD±13.6). Glatiramer acetate group (n=30) mean characteristics: age=52.4 years (SD±11.3), disease duration=15.1 years (SD±10.4), EDSS =5.7 (SD±1.6), follow-up=46.9 months (SD±43.9). Both treatments were well tolerated without serious side effects. After adjustment for age, sex, and baseline EDSS, sustained EDSS progression did not differ between groups (Hazard Ratio =1.17; 95% Confidence Interval: 0.45, 3.08; p=0.75). Sustained T25FW worsening after adjustment also did not differ (Hazard Ratio =0.56; 95% Confidence Interval: 0.2, 1.53; p=0.26).

Conclusions

In an advanced progressive multiple sclerosis population no substantial differences in tolerability, safety, sustained EDSS progression, or sustained T25FW worsening over time were observed between glatiramer acetate and teriflunomide treated groups.

Background

Neurological disability progression occurs across the spectrum of people living with multiple sclerosis (PwMS). Currently, no treatments exist that substantially modify the course of clinical progression in MS, one of the greatest unmet needs in clinical practice. Characterizing the determinants of clinical progression is essential for the development of novel therapeutic agents and treatment approaches that target progression in PwMS.

Objectives

The overarching aim of CanProCo is to evaluate a wide spectrum of factors associated with the onset and rate of disease progression in MS, and to describe how these factors interact with one another to influence progression.

Methods

CanProCo is a prospective, observational cohort study aiming to recruit 1000 individuals with radiologically-isolated syndrome (RIS), relapsing-remitting MS (RRMS), and primary-progressive MS (PPMS) within 10-15 years of disease onset, and 50 healthy controls (HCs) from five large academic MS centers in Canada. Participants undergo detailed clinical evaluations annually. A subset of participants enrolled within 5-10 years of disease onset (n=500) also have blood, cerebrospinal fluid, and MRIs collected facilitating study of biological measures (e.g. single-cell RNA-sequencing[scRNASeq]), MRI-based microstructural assessment, participant characteristics (self-reported, performance-based, clinician-assessed, health-system based), and environmental factors as determinants contributing to the differential progression in MS.

Results

Recruitment commenced in April/May 2019 and n=536 patients have been recruited to date (RRMS=457, PPMS=35, RIS=25, HC=19). Baseline age, sex distribution, and Expanded Disability Status Scale (EDSS) scores (median, range) of each subgroup are: RRMS=38 years, 73% female, EDSS=1.5 (0-6.0); PPMS=52 years, 40% female, EDSS=4.0 (1.5-6.5); RIS=41 years, 68% female, EDSS=0 (0-3.0); HC=37 years, 63% female. Recruitment has surpassed the 50% target but has been paused due to the COVID-19 pandemic. scRNASeq on frozen blood samples has been validated.

Conclusions

Halting the progression of MS is a fundamental clinical need to improve the lives of PwMS. Achieving this requires leveraging transdisciplinary approaches to better characterize mechanisms underlying clinical progression. CanProCo is the first prospective cohort study aiming to characterize these determinants to inform the development and implementation of efficacious and effective interventions.

Background

Background: Alemtuzumab (ALZ) belongs to the immune reconstitution therapies for relapsing-remitting multiple sclerosis (RRMS). ALZ is used as second or third line treatment in clinical practise, thus the real-world population treated with ALZ is markedly different from the populations in the pivotal trials of ALZ.

Objectives

Objectives: To assess basic characteristics and therapeutic effects on clinical and imaging parameters of disease activity for RRMS patients selected for ALZ.

Methods

Methods: RRMS patients were consecutively included at the MS Centre, Gothenburg. Patients were clinically assessed with Expanded Disability Status Scale (EDSS), occurrence of clinical relapses and with cerebral MRI at baseline, month 12, 24, 36 and 48.

Results

Resluts: 51 (31 females) RRMS patients, mean age and mean disease duration of 35.5 (±7.1) respectively 7.1 (±5.4) years were included. Prior to baseline 6 patients had first line treatment, 38 had second line and 7 were naïve. Reasons to switch to ALZ; break through disease activity despite disease modifying treatment (DMT) (n=23), side effects (n=3), positive JC virus antibody test during natalizumab (n=18), highly active disease from disease onset (n=7). All patients received the first course of ALZ, 50 the second, 14 a third, and 2 a fourth course. At baseline, month 12, 24, 36 and 48 median EDSS was 2 (0-7.5), 1.5 (0-7), 1.5 (0-7.5), 1.5 (0-7.5) and 1.5 (0-7), respectively. At 48 months 34 patients were relapse free, and the annual relapse rate was 0.12. Baseline MRI revealed high lesion load; T2 lesions >20 (n=35), T2 lesions 10-20 (n=12), T2 lesions 1-9 (n=4), 36 patients had no contrast enhancement. Upon follow-up at 12, 24 , 36 and 48 months, 39 patients, 42, 45 and 38 had no new or enlarged T2 lesions respectively, corresponding number with no contrast enhancement was 43, 45, 47, and 40. Mean brain parenchymal fraction at baseline was 0.862 (±0.037, n=43) and was unchanged at follow-up. 23 patients met No Evidence of Disease Activity (NEDA) at 48 months. 9 (18%) patients have switched from ALZ to another DMT (rituximab n=6, autologous hematopoietic stem cell transplantation n=3) due to disease activity.

Conclusions

Conclusions: This real-world population confirms that ALZ as second or third line treatment effectively reduced disease activity. Although most of our patients had previously failed on DMT the proportion of progression free survival (82%) and NEDA (45%) were of similar magnitude as those reported from the pivotal trials CARE-MS I&II.

Background

Disease-modifying drugs (DMDs) may result in a high risk of opportunistic infections including progression of primary tuberculosis or reactivation of latent TB (LTB).

Objectives

The aim of this work is to characterize LTB in a population of patients with multiple sclerosis (MS) and to analyze its impact on MS management.

Methods

Retrospective study of MS patients who underwent QuantiFERON-TB Gold (QTF-G) in our centre between January 2015 and May 2019.

Results

Among 367 MS patients, QFT-G was negative in 323 (88%), positive in 35 (10%) and undetermined in 9 (2%). No cases of active infection were detected. Regarding patients with a positive QFT-G, the mean (SD) age was 49.1 (10.7) years, Expanded Disability Status Scale (EDSS) 3.1 (2.0), disease duration 9.7 (8.5) years, treatment duration 7.7 (7.0) years and number of previous DMDs 1.7 (2.1). Ten patients (28.6%) were DMD-naïve. Age, EDSS, disease duration, treatment duration and number of DMDs were not associated with positive QTF-G. All patients with a positive QTF-G were treated for LTB, 34 with isoniazid for 9 months and one with rifampin for 4 months. Two patients (5.7%) developed hepatic adverse effects, resolved after discontinuation of isoniazid, followed by a switch to a 4-month regimen of rifampin, which was started when liver enzymes returned to the normal range. Of the 35 patients with a positive QTF-G, 4 (11%) were started simultaneously on a DMD and LTB treatment regimen and in 31 (89%) there was a postponing of the start/switch of DMD (8 were DMD-naïve, 15 were kept on previous DMD and 8 suspended the previous DMD and were left temporarily without MS medication). The mean (SD) duration of the postponement was 3.4 (3.0) months. Four patients had relapses during the period waiting for the start/switch of DMD.

Conclusions

In our study, the treatment of LTB was effective and relatively safe. As 12.9% of patients had relapses while waiting for the start/switch of DMD, our work suggests that the start of DMDs should not be delayed beyond the 4-8 weeks recommended in the literature.

Background

Biogen Patient Support Programmes (PSP) are designed to address unmet medical needs (education, compliance to therapy, disease management) of patients on treatment with Multiple Sclerosis (MS) disease modifying treatments. The combination of lifesaving drugs and meaningful services could lead to an overall improvement of health outcomes. For the scope of this pilot analysis, UK and German relapsing-remitting MS (RRMS) patients receiving dimethyl fumarate (DMF) have been included.

Objectives

To compare healthcare resource use (HRU), work productivity and activity impairment (WPAI), and quality of life (QoL) outcomes for RRMS patients receiving DMF and enrolled on a PSP for at least 12 months vs. DMF patients not on a PSP (Non-PSP).

Methods

Pilot analysis was conducted using data from the Adelphi MS Disease Specific Programme, a cross-sectional survey of neurologists and MS patients in the UK and Germany between March and September 2019. Propensity score matching on age, gender, EDSS at current DMT initiation, number of lines of therapy, current DMF duration, country and MS nurse involvement in the last 12 months was used to create balanced groups. HRU, WPAI, and QoL were compared between groups.

Results

Among 232 DMF patients, 83 were on a PSP and 149 were Non-PSP. DMF PSP patients reported significantly fewer hospitalizations in the last 12 months overall (0.00 vs 0.06, p=0.020). PSP patients also reported significantly less work impairment due to problem according to the WPAI (18.28% vs 24.05%, p=0.017). PSP patients reported significantly higher EQ-5D scores overall (0.91 vs 0.86, p=0.046). Significantly lower MSIS-29 scores were also reported for PSP patients; patients were less bothered by problems sleeping (1.64 vs 2.18, p<0.001) and lack of confidence (1.53 vs 1.82, p=0.047).

Conclusions

Enrolment on the DMF PSP is associated with reduced burden to the UK and German healthcare systems, providing scope for allocation of resources elsewhere. There was also a reduction in patient’s WPAI and a higher level of QoL for those enrolled on the DMF PSP. These pilot results suggest there may be value in further detailed research to validate the signals seen in this cross-sectional approach.

Study Supported by: Biogen

Background

The COVID-19 pandemic has raised novel questions for people with multiple sclerosis (pwMS), which worldwide registries will help answer. One question is - how will disease modifying treatment (DMT) use affect the efficacy of a future vaccine against SARS-CoV2 (the virus that causes COVID-19) in pwMS? To begin to address this question, we evaluated our patients who were clinically diagnosed with Covid-19 for antibodies (Ab).

Objectives

To determine the frequency of SARS-CoV-2 Ab in our patients with Covid-19 and co-morbid MS, and describe their clincal characteristics.

Methods

This is a case series of pwMS who are patients of the Holy Name MS Center and were either proven by PCR or highly suspected of active COVID-19 infection as of July 15, 2020.

Results

Of the 11 patients included, 91% (n=10) were female, average age 50.5 years (range 34-64 years); 7 patients treated with an anti-CD 20 monoclonal Ab (6 ocrelizumab (OCR), 1 rituximab (RTX)), 1 teriflunomide, 1 interferon beta-1a, and 2 patients not on DMT. Nine tested positive for SARS-CoV2 Ag by nasopharyngeal PCR; 1 was not tested but had a household exposure who tested positive and herself had clinical symptoms of cough, dyspnea, myalgia, weakness, fatigue and headache; and 1 patient tested negative for SARS-CoV2 PCR but was febrile with cough, fatigue and headache during the pandemic. Of this series, 5 tested positive for SARS-CoV2 Ab (Abbott test); of which only 1 was on treatment with OCR (with absent CD19 cells). In terms of clinical outcome – 4 patients (all OCR/RTX treated) required hospital admission for supplemental non-invasive oxygen. All patients survived infection.

Conclusions

This case series suggests that MS treatment with monoclonal anti-CD20 drugs may be associated with some increased risk of developing COVID-19. All of our patients who required hospitalization for this infection were treated with anti-CD20 threapy. Patients with MS who are on OCR/RTX may be less likely to mount an antibody response to this infection, whereas patients treated with interferons and teriflunomide can. Lack of seroconversion following OCR treatment was also noted in another case series of pwMS (Thornton 2020). Although it is reassuring that B-cells are not required to recover from COVID-19 infection, as evidenced by a case series of X-linked agammaglobulinemia patients (Soresina et al. 2020), our findings raise further questions for the health and safety of our patients with respect to this pandemic. Will OCR treated patients be at a unique risk to suffering reinfection from COVID-19 given they are less likely to seroconvert? And, how effective will a future vaccine be in patients treated with OCR (and similar monoclonal antibodies)?

Background

Daytime sleepiness is one of the sleep disorders described in multiple sclerosis (MS) that can affect the quality of life of patients, especially in the presence of associated fatigue.

Objectives

Daytime sleepiness is one of the sleep disorders described in multiple sclerosis (MS) that can affect the quality of life of patients, especially in the presence of associated fatigue.

Study the prevalence of daytime sleepiness in our multiple sclerosis patients.

Methods

Cross-sectional study carried out in the neurology department at CHU HASSAN II involving 50 patients. The scores used in this work are: the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index (PSQI) score, the EMIF-SEP scale, and the EDSS.

Results

The average age is 39.5 years with a predominance of women. The relapsing remitting form represents 84%, The average EDSS of the patients is 3.45. 60% have sleep disorders with a PSQI greater than 5, of which 34% of patients have daytime sleepiness.

Conclusions

Sleep disturbances are common and polymorphic in MS patients. Daytime sleepiness is a handicap during daily activity and can lead to serious accidents. It is often associated with fatigue and the distinction between the 2 symptoms is not obvious. Modafinil could improve both daytime sleepiness and fatigue.

Identifying and managing this sleep disorder could improve the quality of patients lives.

Background

Therapeutic inertia is defined as a failure to initiate or intensify treatments despite clinical and paraclinical evidence of disease activity. Its prevalence and determining factors in Relapsing-Remitting Multiple Sclerosis (RRMS) patients in Portugal are not known.

Objectives

Our primary goal was to determine the frequency of therapeutic inertia in our RRMS patients; our secondary goal was to describe therapeutic inertia predisposing factors.

Methods

A multicentre retrospective observational study was performed. We studied patients with RRMS followed in MS Clinics of six Portuguese hospitals with at least one medical appointment during the study period (January 1^st to December 31^st 2018).

Results

We included 427 patients with RRMS, 69.6% females, with a mean age of 41.66 years-old and a mean age at diagnosis of 33.17 years-old. The average number of years since diagnosis was 8.72. MS relapses were reported on 54 patients. Median EDSS score was 1.5 (IQR=1.5). Among the 365 patients who underwent MRI during the study period, 23.8% had new T2 lesions and 7.4% had lesions with contrast enhancement. Therapeutic inertia was present in 80 patients, representing 18.7% of the total sample and 54.8% of the patients with potential to inertia (indication for treatment escalation). Patients with no more than one new T2 lesion, no gadolinium-enhancing lesions, already on a DMT, without adverse events from their current DMT and who were followed in higher care level centres were more likely to have therapeutic inertia (p<0.05). In a binary logistic regression model, the current treatment with DMT (p=0.050), the absence of adverse events (p<0.001), the higher care level (p=0.015) as defined in the Hospital Referral Network in Neurology, and the absence of relapses (p=0.021) or the presence of mild relapses (p=0.027) had an independent effect in therapeutic inertia.

Conclusions

Therapeutic inertia was present in about 1 in 5 patients, exceeding half of the population when considering all the patients with potential to inertia. The subgroup of patients with indication for therapeutic escalation and which also have less active radiological disease was associated with more therapeutic inertia, although these results were not confirmed in a multivariate analysis. Attending a higher care level center, being under DMT, absence of adverse events, and having none or mild relapses, were determining factors for therapeutic inertia.

We believe this study raises awareness to therapeutic inertia as an important problem, providing further knowledge on predisposing factors that may be adressed in MS care.

Background

The rapid development of MS disease modifying therapies (DMTs) has substantially complicated decision-making for clinicians. Despite the availability of 18 DMTs spanning nine therapeutic classes, few of these agents have been compared head-to-head and only recently were consensus-based guidelines published on their use. Almost no publicly available information exists about how practicing neurologists are approaching the contemporary management of this population.

Objectives

To assess potential discrepancies in clinical decisions between neurologists who specialize in MS and those who treat MS but do not subspecialize.

Methods

An online survey was conducted in May 2020. US and Canadian neurologists practicing in academic or specialized MS centers were invited to participate. A random sample of US generalists who practice in community-based, non-specialized settings but see 5-20 MS patients each week were also recruited. Questions were formulated to assess differences regarding strategic approaches to case-based scenarios.

Results

A total of 25 experts and 100 general neurologists completed the assessment. Experts were more likely to offer high efficacy DMTs across a variety of clinical presentations (e.g. CIS by age, RRMS, pregnancy, PPMS). For a 25-year-old female patient with CIS, the largest cohort of experts prioritized ocrelizumab (30%) vs. 2% of generalists (p<0.001). Generalists preferred glatiramer acetate (GA) (34%) vs. 0% of experts (p<0.001). For a 29-year-old female (JCV negative) with moderate risk disease, 84% of experts selected either natalizumab or ocrelizumab, compared to 43% of generalists (p<0.001). For a 29-year-old with higher risk MS and plans to become pregnant, 76% of experts chose ocrelizumab (8% of generalists, p<0.001) while 44% of generalists recommended GA (0% of experts, p<0.001). Both groups trended more towards high efficacy therapies in response to radiologic disease activity vs. clinical relapses with stable imaging.

Conclusions

There were several group commonalities including DMT initiation, the impact of race, and therapeutic response to breakthrough disease. However, substantial differences were seen in DMT choice, switching behavior, use in patients contemplating pregnancy, and age variation. Experts typically prioritized higher efficacy agents while generalists typically prioritized safety profile. This suggests that approaches are heterogenous and greater education among generalists may be warranted.

Background

Patients with multiple sclerosis (MS) change and discontinue disease-modifying therapies (DMTs) for a variety of reasons. Relatively little is known about the dynamics of these changes across different DMTs.

Objectives

This objective of this study examined patterns of DMT change, discontinuation, and restart in patients with newly diagnosed MS.

Methods

Adults with newly diagnosed MS were identified in the IBM MarketScan Commercial and Medicare databases. Eligible patients had ≥12 months of continuous enrollment prior to their initial MS diagnosis and ≥2 years of follow-up from January 2007 to October 2017. Patients with evidence of pregnancy or any malignancy during the study period were excluded. Up to 3 courses of DMTs were reported during a follow-up period of 2 to 10.5 years. Discontinuation was defined as having a gap in therapy of ≥60 days. Restarting was defined as reinitiating the same DMT after a 60-day gap.

Results

In total, 14,627 newly diagnosed MS patients were treated with DMTs and had ≥2 years of follow-up. Of these, 25% had 2 DMT courses and 27% had 3 DMT courses during follow-up. Half of treated patients discontinued their first DMT course, but 52% of those who discontinued their first course restarted the same DMT for their second course. Mean time to restart was 165 days (median: 93 days). Patients taking glatiramer acetate (GA) and interferon beta-1b (IFN β-1b) had the highest rates of discontinuation during the first DMT course (52% and 55%, respectively) and the highest rates of restart among those who discontinued (57% and 56%, respectively). Of all patients who discontinued, those taking oral DMTs (dimethyl fumarate, fingolimod, and teriflunomide) had discontinuation rates of 43%–50% and restart rates of 31%–38%. Natalizumab had the lowest rate of discontinuation (37%) and restart (20%). Among the 7,510 patients with any second treatment course, the overall discontinuation rate increased to 56% and the rate of those who restarted their second DMT as their third course increased to 56%. Similarly, GA and IFN β-1b had the highest discontinuation and restart rates among those with a second course.

Conclusions

Over 2 to 10.5 years of follow-up, treatment discontinuation and extended treatment gaps occurred frequently among DMT-treated patients with MS. Returning to the same DMT was surprisingly common.

Background

Recently, the growing number of first-line Disease Modifying Therapies (DMTs) available in clinical practice increased the complexity of treatment choices in naive Relapsing Remitting Multiple Sclerosis (RRMS).

Objectives

We aimed to evaluate if baseline factors such as older age, being a childbearing-aged woman and having comorbidities influenced the choice of the first-line DMT and to analyze switching patterns between different first-line DMTs in a real-world sample.

Methods

We included all consecutive RRMS patients diagnosed between 2016-2020 with a minimum follow-up of 6 months, proposed to an EMA-approved first-line DMT. The DMTs were dichotomized as injectable (BRACE) vs oral DMTs (dimethyl fumarate, teriflunomide). We performed a binary regression to assess if age ≥ 55 years, being a childbearing-aged woman and having comorbidities influenced DMT choice.

The risk of DMT switch at follow-up was evaluated using a Kaplan-Meyer survival analysis with a log-rank test.

Results

107 patients were included in the analysis, 71 (66.4%) female, mean age 35.7±12.1 years. The majority of patients starting a first-line treatment (58.9%) started an oral DMT.

Childbearing-aged women were almost 3 times more likely to be proposed to injectable treatment (OR 2.860, 95%CI 1.191-6.864, p=0.019), while older age and the presence of comorbidities did not influence DMT choice (p>0.05).

During a mean follow-up of 23.6 months, 34 (31.8%) patients switched treatment, the majority (61.8%) due to treatment failure. The survival analysis revealed a higher risk of treatment switch during follow-up in patients starting injectable DMTs (HR 0.475, 95%CI 0.240-0.943, log rank p=0.029).

Conclusions

The oral DMTs have become the most common first-line treatment in the contemporary management of naive-RRMS. Being a childbearing-aged woman, however, seemed determinant in the proposal for an injectable DMT, probably due to the higher safety of these drugs during pregnancy.

The oral DMTs were associated with a lower risk of treatment switch and might be considered from early stages on to enhance treatment persistence.

Background

The TREAT-MS study (Paul-Ehrlich-Institut registry: 281) is assessing real-world effectiveness of alemtuzumab in relapsing-remitting multiple sclerosis (RRMS) patients in Germany.

Objectives

Subgroup analysis of TREAT-MS to investigate the effect of the number of prior disease-modifying therapies (DMTs) on the efficacy and safety of alemtuzumab 1 year after the 2nd treatment cycle with alemtuzumab.

Methods

TREAT-MS is a 5-year, observational, longitudinal, noninterventional, open-label, multicenter study of alemtuzumab-treated patients.

Results

As of February 2020, 883 patients were enrolled and 571 patients were observed for 2 years after treatment initiation. Of these, 565 (98.9%) patients entered the first treatment period, 538 (94.2%) patients entered two treatment periods. 13.3% of patients were treatment-naive at baseline, 83.7% had received prior DMTs, and in 3.0% pretreatment was unknown. The interim analysis focussed on the data of patients 1 year after the 2nd treatment phase and was differentiated by the number of previously received DMTs. Patients with 0, 1, 2, and ≥3 pretreatments had a mean number of 1.6, 1.7, 1.4, and 1.8 relapses, respectively, during the last 12 months before alemtuzumab treatment. After alemtuzumab treatment initiation, annualized relapse rate (ARR) in patients with 0, 1, 2, ≥3 pretreatments reached levels of 0.13, 0.18, 0.25, and 0.24. ARR after alemtuzumab initiation was significantly higher in patients who received 2 or ≥3 prior DMTs when compared with treatment-naive patients.

The majority of patients were relapse-free 1 year after the 2nd course of alemtuzumab. 82.2%, 77.0%, 66.5%, 73.1% of the patients with 0, 1, 2, ≥3 pretreatments, respectively, had no relapses during the observational period. The proportion of relapse-free patients 1 year after the second alemtuzumab course was highest in treatment-naive patients.

Mean expanded disability status scale (EDSS) score at baseline was 2.2, 2.4, 2.6, and 3.6 for those who received 0, 1, 2, and ≥3 prior DMTs, respectively, and changed by a mean EDSS value of –0.5, –0.2, –0.2, and –0.5 one year after the 2nd treatment phase.

Adverse events were reported for 64.5%, 66.9%, 66.9%, 73.6% of the patients treated with 0, 1, 2, and ≥3 DMTs. No new safety signals were observed.

Conclusions

The interim subgroup analysis of patients 1 year after the 2nd treatment cycle with alemtuzumab has shown that relapse rates were reduced, and EDSS scores were stable regardless of the number of prior DMTs received. These data confirm registration trial findings (CARE-MS I and II) in the real-world setting in patients with longer disease duration and varying treatment history.

Background

Over the past decade, numerous disease modifying drugs (DMDs) for relapsing multiple sclerosis (RMS) have been approved in Argentina. It is believed that the use of oral DMDs (oDMDs) i.e. fingolimod, teriflunomide and dimetil fumarate has increased in recent years, although the real-life data in our country is limited.

Objectives

Our aim was to describe the tendency of the use of oDMDs (as first treatment option or after switch) regarding its approval in Argentina.

Methods

A retrospective study was conducted in a cohort of MS patients follow-up in five Argentinian MS centers incorporated in the Argentinean MS and NMOSD registry (RelevarEM, NCT 03375177). Patients who started their treatment since 2012 were included. Regarding to the availability of different oDMDs in Argentina, we define three period (P1-3): P1: 2012 – 2014; P2: 2015 - 2017 and P3: 2018 - 2020. An analysis was performed comparing between these three periods to assess the tendency of oDMDs use over time. Three scenarios were defined: initial treatment, first switch and second switch. For the switch scenarios, only P1 and P2 were analyzed considering that the patients belonging P3 have a short evolution time and a scarce patient’s number required treatment changes.

Results

Out of 202 patients, 58% were female, mean age 32.4 ±11.0 years, mean disease evolution 8.0 ±5.5 years, 46 % started with oDMDs and 64% was the first choice after a switch. Injectable therapies were the most frequently withdrawn in relation to oDMDs and monoclonal antibodies (p<0.01). The main cause of switching treatment was treatment failture (39%). We found an increase in the use of oDMDs as initial treatment over time (P1: 17.7%, P2: 63.9% and P3: 65.0%; p <0.01). We found a tendency in increasing use of oDMDs after a first switch (P1: 59.6%, P2: 73.1%) or second switch (P1: 59.6%, P2: 73.1%). Multivariate analysis showed that disease evolution (OR=1.06, p=0.04), and year of starting treatment (OR=0.66, p<0.01) were independently associated with choice of oDMDs.

Conclusions

We have identified an increasing tendency in the use of oDMDs as initial treatment of RMS regarding its approval in Argentina.

Background

Real-world data (RWD) are an important complement to randomized, controlled and registry datasets in defining a disease course longitudinally. There is growing interest in understanding the insidious progression in multiple sclerosis (MS) that can occur despite aggressive relapse prevention, as well as how diversity and comorbidities impact multiple sclerosis (MS) patients, particularly in the era of the coronavirus (COVID19) pandemic.

Objectives

We aim to derive RWD from a diverse cohort of approximately 4,000 MS patients in Northern California to pair with biomarkers from the Sutter-wide Precision Medicine Biobank – a longitudinal biorepository with a healthy aging comparator cohort. This pilot of 34 patients evaluates the integration of several data sources to extract key information about disease course. From the EHR, we use a combination of text processing, automated data element extraction, manual chart curation, and patient- and physician-targeted questionnaires to form a real-world dataset of interpretable outcome metrics.

Methods

This is an ambidirectional cohort study of subjects at least 18 years old, with a defining diagnosis of MS from at least one hospitalization or two outpatient encounters. Data elements including demographics, medication orders and comorbidities were directly extracted from the EHR. MRI reports in text format were stored in an Epic Clarity database, and neurology notes were mined for terms indicating stability versus worsening. Manual curation was used to transform prose clinician notes into tabular-format outcome scores.

Results

We curated 9930 total encounters, 136 brain MRI reports and 137 spine MRI reports. We found 7.5 years (+/- 3.3) of data per patient in this pilot of 34 patients. 79% of patients were female, 21% male; 68% white, 26% black and 6% other/not disclosed. The most common disease-modifying therapies used were natalizumab, dimethyl fumarate and glatiramer acetate. 68% of patients had at least one comorbidity, 35% specifically had hypertension. Using automated and manual data methods, we were able to compile metrics of clinical and radiographic worsening versus stability from information in the EHR.

Conclusions

Our methods may be used to generate interpretable data on a system-wide scale from the comprehensive, longitudinal data of an EHR. These RWD can be paired with biospecimens, research assessments, and other datasets to add to the diversity of data on MS natural history and medication response.

Background

Vitamin D deficiency is a known risk factor for multiple sclerosis (MS) and is associated with worsening disease activity and disability.

Objectives

To examine the association between vitamin D with clinical outcomes, patient reported outcomes and quantitative MRI measures in a real-world MS cohort.

Methods

We conducted a retrospective analysis of patients enrolled in the Cleveland Clinic Clinical Practice Data Registry between June 2015 and November 2019. Serum 25-hydroxyvitamin D₃ levels collected within 90 days of the first multiple sclerosis performance test (MSPT) assessment were recorded. Patients were dichotomized as sufficient or insufficient using a cutoff of 30 ng/mL. Baseline demographics, vitamin D supplementation, clinical outcome measures [Processing Speed Test (PST), Manual Dexterity Test (MDT), and Walking Speed Test (WST)], and patient reported outcome measures (PROMs) were collected. Brain/cervical MRIs obtained +/-90-days from the initial MSPT were analyzed via fully-automated methods for spinal cord cross sectional area (SCA), whole brain fraction (WBF), and T2 lesion volume (T2LV). Vitamin D associations were determined using Pearson correlation, quantile regression, and linear regression analysis.

Results

369 patients (median age 47.3 years, 71.0% female, and 79.7% caucasian) were included in the analysis. Median age at diagnosis was 35 (IQR[interquartile range] 29.0-43.0), and median years with MS was 12.3 (IQR 5.49 – 20.6). Median vitamin D levels were 34.1 ng/mL [IQR 24.4;46.7] and 68.6% of patients were on supplementation. 62.3% (n=230) had sufficient vitamin D levels and 37.7% (n=139) had insufficient levels. No statistically significant differences were found between the groups for season at assessment, patient reported relapses, PST, MDT, or any quantitative MRI metrics The vitamin D insufficient [OD1] group had a statistically significantly longer WST (median 7.35 vs 6.56, p-value = 0.028). MDT dominant hand time had a statistically significant inverse relationship with vitamin D levels (ρ = -0.145) (p-value=0.005), which became non-significant after regression adjustment.

Conclusions

Vitamin D levels were found to be sufficient in two-thirds of patients and is likely explained by supplementation. Patients at sufficiency had faster walking speeds, but no other differences were found on clinical/MRI measures. We hypothesize that supplementation obscures the relation between vitamin D levels and clinical/MRI measures.

Background

background: Endoplasmic reticulum (ER) stress is strictly linked to neuroinflammation and involves in the development of neurodegenerative disorders. Protein disulfide isomerase (PDI) is an enzyme that catalyzes formation and isomerization of disulfide bonds and also acts as a chaperone that survives the cells against cell death by removal of misfolded proteins.

Objectives

Our previous work revealed that PDI is explicitly upregulated in response to myelin oligodendrocyte glycoprotein (MOG)-induced ER stress in the brain of experimental autoimmune encephalomyelitis (EAE) mice. The significance of overexpression of PDI in the apoptosis of neural cells prompted us to study the effect of CCF642, an efficient inhibitor of PDI, in the recovery of EAE clinical symptoms.

Methods

The animal model of EAE was produced by the “Salari Institute of Cognitive and Behavioral Disorders”. The hippocampal tissues were homogenized in RIPA buffer, and the total protein concentration was determined by Bradford assay. PDI activity was measured by the reduction of insulin in the presence of dithiothreitol (DTT; Merck, Germany) as a reducing agent.To prepare protein samples, the hippocampus tissues were homogenized in ice-cold lysis buffer containing 50 mM Tris-HCl (pH = 8), 150 mM NaCl, 1% SDS, 1 mM EDTA and 0.5% sodium deoxycholate supplemented with 1 μg/ml pepstatin, 10 μg/ml leupeptin, 60 μg/ml aprotinin and 1 mM phenylmethylsulfonyl fluoride (PMSF; all chemicals obtained from Sigma). The activity of Caspase-12 in the hippocampus of mice was determined using a fluorometric assay according to the specified manufacturer’s protocol for Caspase 12 Assay Kit (ab65664, Abcam, Cambridge, MA, USA). Double staining of terminal deoxynucleotidyltransferase-mediated dUTP nick-end labeling (TUNEL) and neuronal marker (NeuN) was carried out to explore colocalization of apoptotic cells and neurons. Hematoxylin (Sigma, USA) and eosin (Sigma, USA) staining were used to evaluate inflammation in the hippocampus of mice. Frozen hippocampus tissues (n = 10 each group) were homogenized in ice-cold lysis buffer used in western blotting. The obtained lysates were used to measure IL-1β, IL-6, IL-17, IL-23, IFN-γ, and Bcl2 by commercially available ELISA kits. Total protein concentration in the supernatants was detected using the Bradford assay. Data are presented as the mean ± SD. The significant differences between the two groups were calculated by the Student′s t-test or Mann-Whitney U test where appropriate

Results

Our observations suggested that CCF642 administration attenuates EAE clinical symptoms and the expression of ER stress-related proteins. Further, it suppressed the inflammatory infiltration of CD4 + T cells and the activation of hippocampus-resident microglia and Th17 cells.

Conclusions

We reported here that the inhibition of PDI protected EAE mice against neuronal apoptosis induced by prolonged ER stress and resulted in neuroprotection.

Background

Current evidence indicates that neurodegeneration (NDG) is a prominent feature in the pathogenesis of MS, and the primary cause of disability in MS patients. Yet, knowledge of the molecular mechanisms of NDG in MS, as well as treatment options to prevent or reverse NDG, is lacking. Exploration of perturbed molecular mechanisms in MS may allow us to develop therapies that attenuate NDG and in turn, inhibit disability, and improve long-term quality of life of persons living with MS

Objectives

To characterize somatic (acquired) MS genetic mutations in A1 that cause molecular dysregulation of A1, using innovative cutting-edge optogenetic technology, and elucidate the role of dysregulated A1 in the pathogenesis of NDG in a model of MS.

Methods

We created optogenetic A1 protein expression constructs containing wildtype (WT) and mutant A1, tagged with both the optogene Cryptochrome 2 (Cry2) and mCherry. Cry2 is an optogenetic protein that self-clusters in response to blue light (BL) stimulation, and reverses when BL is turned off, therefore allowing real-time examination of protein clustering kinetics. We established an in vitro optogenetic paradigm of A1 dysfunction in HEK293T cells and gathered evidence of how select mutations affect A1 cellular localization and function.

Results

Using a chronic, single BL stimulus followed by a steady period of recovery (imitating chronic environmental cell stress), our data showed that the MS associated A1 mutations pP275S and pF281L increased the kinetics of both cytoplasmic cluster formation [17 and 32 minutes, respectively, compared to 51 minutes for WT (p < 0.0001)] and clearance of A1 [22 and 26 minutes, respectively, compared to 19 minutes for WT (p < 0.05)]. A1 clusters also decreased in quantity [clusters/cell: pF281L=2.1; pP275S=3.2; WT=3.4 (p < 0.05)] and increased in size [average cluster size (µm²): pF281L=0.37; pP275S=0.49; WT=0.24 (p < 0.001)], compared to WT. These data demonstrate changes in the molecular function of mutant A1 compared to WT, indicative of A1 dysfunction.

Conclusions

Using an in vitro optogenetic approach, this study presents evidence that somatic MS genetic mutations in A1, found in MS patient tissue, promotes A1 mislocalization and self-association, leading to protein dysfunction that may have an effect on NDG in MS pathogenesis.

Background

Although meningeal B-cell infiltrates characterize progressive disease and cortical pathology in multiple sclerosis (MS), active and mixed active/inactive white matter lesions with lymphocytic infiltrates are also observed in advanced MS autopsy cases.

Objectives

We assessed the association between B-cell presence in brainstem and white matter lesions with pathological and clinical characteristics in MS autopsy cases.

Methods

Autopsy tissue of 140 MS and 24 control cases, as well as diagnostic biopsies of 24 MS patients were examined for CD20+ B cells and CD138+ plasma cells. Presence of these cells was compared to pathological and clinical characteristics. In corresponding cerebrospinal fluid (CSF) and plasma, immunoglobulin (Ig)G ratio and oligoclonal band (OCB) patterns were determined. In a clinical cohort of 73 patients, the presence of OCBs was determined at diagnosis and during follow-up.

Results

B cells were mostly found in the perivascular space and the meninges, but were also enriched in active and mixed active/inactive white matter MS lesions. In 34% of active and 71% of mixed active/inactive lesions, B cells were absent, which correlated with less pronounced meningeal B-cell infiltration. In an extreme of outcomes-analysis, donors without B cells or plasma cells at all locations analyzed, displayed a longer disease duration, less frequent secondary progressive MS, and a lower proportion of mixed active/inactive lesions when compared to donors with B cells and/or plasma cells at all locations. Moreover, a lower CSF IgG ratio and more frequent absence of OCBs were noted. In a clinical cohort, numbers of patients without OCBs in CSF were increased at follow-up.

Conclusions

Absence of B cells is associated with a favorable clinical and pathological profile. This finding may reflect extremes of a continuum of genetic or environmental constitution, but also a regression of white matter humoral immunopathology in the natural course of advanced MS.

Background

Multiple sclerosis (MS) is a chronic, inflammatory neurodegenerative disease affecting more than 2.3 million people worldwide and for which, there is no cure currently. The etiology of the disease is multifactorial including genetic predisposition, abnormal immune responses and environmental factors. One environmental factor in particular, exposure to EBV, has been associated with MS through increased antibody titers to EBV viral proteins in the blood and the cerebrospinal fluid. EBV is a ubiquitous human herpesvirus latent in B-cells where 95% of the population by young adulthood are known to be positive by seropositivity rate. EBV causes infectious mononucleosis (IM) and individuals who have had IM have a higher risk of developing MS.

Objectives

Compare the frequency and magnitude of detection of EBV-DNA by digital droplet PCR (ddPCR) in normal donors (ND) and stable and active MS patients.

Methods

25 stable and 25 active MS patients and 26 ND were analyzed in this study. Active patients were defined as patients with ≥ 1 cerebral enhancing lesions (CEL) at the sample date. PBMCs and CD19⁺-B cells sorted by flow cytometry and magnetic beads were analyzed. DNA was extracted and used as templates to evaluate the presence of EBV-DNA by ddPCR. EBV copy number per 10⁶ cells was assessed for the BAMHI region of EBV compared to the housekeeping gene, RPP30.

Results

Our data show that the frequency of EBV positive CD19⁺ cells in active MS patients was significantly elevated (20/25, 80%) compared to stable MS patients (7/25, 28%; p=0.0002) and normal controls (11/26, 42%; p=0.006). To evaluate if the increase in the frequency of EBV positivity in the active MS patients was specific for EBV, cells from these cohorts were used to amplify another ubiquitous B cell tropic virus, JCV, that also establishes latency in B cells. JCV was not detected in any of the active MS patients CD19⁺ cells. These data demonstrate that the increase in the frequency of EBV DNA detection in active MS patients in comparison to the stable and the ND controls was specific to EBV. Significant difference was also observed in the frequency of detection of EBV DNA between the active (9/25, 36%) versus the stable MS patients (3/25, 12%; p=0.047) when PBMCs were used as template to amplify EBV-DNA. However, the magnitude of the EBV viral load was not significantly different between the three cohorts as determined by ANOVA test.

Conclusions

Our experiments indicate that in active MS patients the percentage of CD19⁺-B cells positive for EBV-DNA is doubled in contrast to stable MS and normal donor controls supporting a role for EBV in the pathogenesis of MS. Our data indicate that the use of sorted CD19⁺ B cells versus total PBMCs may be a more sensitive method for EBV-DNA detection.

Background

Abnormalities in expression of RNA-binding proteins (RBPs) have been shown to be involved in the pathogenesis of a number of disorders, most notably amyotrophic lateral sclerosis. Recent data demonstrates these RBP abnormalities were also found in the brains of patients with multiple sclerosis (MS) and MS models. Oligodendrocyte-mediated myelination of neuronal axons is essential for axonal integrity and protects neurons from degeneration. Myelin basic protein (MBP) and myelin-associated glycoprotein (MAG) are the two major components of central nervous system (CNS) myelin. The transport and translation of MBP and MAG mRNAs in oligodendrocytes are regulated by diverse RBPs. Our lab previously demonstrated that dysfunction of RBPs including heterogeneous nuclear ribonucleoprotein A1 (hnRNP A1) in neurons is a key contributor to neurodegenerative-mediated mechanisms in MS and its models. Therefore, neurodegeneration is a component of MS pathology, however, the underlying mechanisms behind this remain unknown.

Objectives

We tested the hypothesis that myelin-related RBPs are differentially expressed in the CNS of mice with experimental autoimmune encephalomyelitis (EAE).

Methods

EAE was induced in female C57BL/6 mice by immunization with myelin oligodendrocyte glycoprotein (MOG_35-55). Animals (n=4 each EAE and naïve control) were observed clinically and spinal cord tissues were harvested at the peak of EAE for detection of the myelin related RBPs hnRNP A1, A2, K, E, and F using western blot.

Results

Quantitative analyses showed a significant increase in hnRNP A1 protein expression (p=0.007, unpaired tailed t-test) in spinal cords of mice with EAE. In contrast, hnRNP A2 (p=0.03) and hnRNP K (p=0.002) showed reduced expression. There were no significant differences in the expression levels of hnRNP E and F comparing EAE with naïve animals.

Conclusions

These data indicate that altered expression of the myelin-related RBPs hnRNP A1, hnRNP A2, and hnRNP K may contribute to demyelination and neurodegeneration in EAE, which might also apply to the pathogenesis of MS.

Background

Autoimmune disease like MS present with a loss of tolerance against endogenous proteins. Regulatory T cells (Tregs) maintain homeostasis between immune activation and suppression; however, in MS the mechanisms dependent on thymically produced Treg cells appear insufficient to prevent the initial priming of encephalitogenic T cells. Using an animal model of MS (experimental autoimmune encephalomyelitis (EAE)), we have shown that neuroinflammation and clinical symptoms can be prevented or even completely ameliorated by extrathymically induced antigen specific Tregs following tolerogenic gene immunotherapy. Historically, antigen specific therapies have remained elusive due to the myriad of known and unknown encephalitogenic epitopes present in patients due to differing HLA/MHC backgrounds. Developing a treatment capable of overcoming these hurdles may provide the most effective option for patients suffering from MS.

Objectives

Demonstrate the efficacy and dynamic ability of a novel Adeno-Associated Virus (AAV) gene immunotherapy to not only prevent disease onset, but to also ameliorate 'reverse' preexisting demyelinating EAE disease: 1) induced with various immunodominant and non-dominant encephalogenic myelin oligodendrocyte glycoprotein (MOG) antigens and, 2) do so in multiple strains of mice that have different HLA/MHC genetic backgrounds. Overall, validating the ability of the vector to be an effective therapy without prior knowledge of antigens or genetic background.

Methods

Demyelinating EAE disease was induced in genetically diverse mice (C57BL/6, H2^b; DBA/1, H2^q; SJL/J, H2^s) using combinations of immunogenic epitopes (MOG_35-55, MOG_79-96, MOG_92-106, or MOG_1-125) emulsified in adjuvant. For Prevention, mice were given a single dose of a hepatocyte directed AAV vector expressing MOG that induces antigen specific Tregs and restore immune tolerance or control vector, 2-weeks prior to inducing EAE. For Reversal of preexisting disease, the therapeutic vector was given after disease onset as mice reached various predetermined levels of disease severity. Mice were monitored daily for changes in clinical score.

Results

For Prevention: Mice receiving the therapeutic vector showed no signs of disease onset, cellular infiltration or demyelination within the spinal cord. In contrast, controls developed inflammation and severe demyelinating EAE. For Reversal: Treated mice had lower disease peaks and a significant reduction in neurological impairment (clinical score returned to near baseline) with virtually no cellular infiltration or demyelination, compared to controls.

Conclusions

We have developed and demonstrated efficacy of a powerful AAV gene immunotherapy capable of dynamically adjusting to the unique antigen requirements needed to restore tolerance and independent of genetic background. This gene immunotherapy has the potential to be a paradigm shifting treatment options for MS.

Background

Pregnancy is a special period within the clinical course of multiple sclerosis (MS), characterized by a reduction in the relapse rate and slower disease progression. On the contrary, during puerperium, relapse rate increases again. Viruses have been related to the etiopathogenesis of the disease, especially with disease activity.

Objectives

To analyse the serum antibody titters against Epstein-Barr virus (EBV) (EBNA-1 and VCA) and human herpesvirus 6 A/B (HHV-6A/B), as well as the expression of the envelope protein of the MS-associated retrovirus (MSRV ENV) in pregnant MS patients during pregnancy and postpartum. To study their possible relationship with the disease activity during pregnancy and postpartum, as well as their potential role in predicting the risk of relapses.

Methods

Serum samples were collected from 71 pregnant women, 50 with MS and 21 healthy controls, at every trimester of pregnancy and in the postpartum. Antibody titters against the above mentioned viruses were analysed by ELISA commercial kits, following manufacturer instructions; gene expression of MSRV ENV was analysed by qRT-PCR.

Results

IgM titres against HHV-6A/B were higher in MS patients than in healthy controls in the three trimesters of pregnancy and in the postpartum period (U-Mann Whitney): p =0.00001 for the first trimester; p=0.021 for the second trimester; p = 0.000005 for the third trimester; p =0.001, for the postpartum period). Furthermore, IgM titres against HHV-6A/B in the first trimester were higher in patients with relapses (U Mann Whitney, p = 0.052). Regarding the expression of MSRV ENV, the percentage of positivity during the first trimester was significantly higher in MS patients with relapses during pregnancy compared to those who did not (Fisher, p = 0.038).

Conclusions

High IgM titters against HHV-6A/B and the expression of MSRV ENV during the first trimester of pregnancy could act as predictors of relapse risk during pregnancy / postpartum. Although further studies are needed to validate these results, this study support the relation between viruses and relapses in pregnant MS patients.

Background

Cortical demyelination is thought to be a substrate for diffuse cognitive impairment often seen in the progressive stage of multiple sclerosis (MS). Unlike white matter plaques in brain or spinal cord, cortical MS lesions lack inflammatory T-cell infiltrates. B-cell depleting anti-CD20 therapy is effective in the relapsing-remitting course of MS, however not much is known about a possible effect of anti-CD20 directed therapy in prevention of cortical grey matter demyelination.

Objectives

We recently developed a new rat model (Ücal et al., 2017), suitable for research of cortical demyelination and associated cellular hallmarks seen in progressive MS. The aim of our study was to investigate the effect of anti-CD20 therapy on the development of cortical grey matter pathology in this model.

Methods

Adult male Dark Agouti rats were implanted with a catheter into the cerebral cortex, immunized with a low dose of a recombinant myelin oligodendrocyte glycoprotein (MOG) in incomplete Freund’s Adjuvant and injected with pro-inflammatory cytokines through the catheter to induce cortical demyelination. Anti-CD20 antibody therapy was administered either after (Group 1) or before (Group 2) MOG immunization by intravenous injection into the tail base vein. Rats were sacrificed at peak disease (day 15 post-cytokine injection). Cortical demyelination, microglial activation, neuronal cell loss, astrocytic reactivity and apoptotic cells were assessed by immunohistochemistry using specific markers (PLP, Iba1, NeuN, GFAP, Caspase3, respectively).

Results

Histological analysis demonstrates a significant reduction of demyelination, microglial activation, neuronal loss, astrocyte activation as well as apoptotic cells in anti-CD20 treated animals, compared to animals treated with an isotype-matched control antibody. Both therapeutic approaches (Group 1 and Group 2) showed equal efficacy. There was no significant difference in cortical demyelination between the healthy control animals (0.0 PLP loss) and the anti-CD20 treated animals (Group 1 = 0.1 PLP loss/mm²; Q1 = 0.03, Q3 = 0.27; Group 2 = 0.1 PLP loss/mm²; Q1 = 0.02, Q3 = 0.07).

Conclusions

Anti-CD20 therapy preserves the investigated cortical structures in our animal model, indicating a role of B-cells in the formation of cortical pathology, presumably through various pathways. These findings pave the way for further research on the mode of action of B-cells and might improve our understanding of cellular mechanisms behind progressive MS. This may expand our therapeutic strategies for MS patients in the progressive disease stage.

Background

Autoantibodies are a hallmark feature of numerous neurologic disorders, including multiple sclerosis (MS) and Neuromyelitis optica (NMO) even though the exact pathogenic role(s) and mechanism(s) associated with these autoantibodies are not fully understood. Within the CNS, antibodies can bind to both activating and inhibitory Fc-Receptors (FcRs) that are expressed on barrier-associated macrophages, microglia and other trafficking immune subsets. While well understood in peripheral myeloid cells, the pathophysiological significance of autoantibody-induced FcR signaling in microglia remains unknown, in part due to the lack of a robust in vivo model.

Objectives

Develop an in vivo model to assess Fc Receptor (FcR) and Bruton's tyrosine kinase (BTK) dependent antibody-induced microglia activation.

Methods

Anti-Myelin oligodendrocyte glycoprotein (MOG) monoclonal antibodies (mAbs) were generated and injected peripherally. Anti-MOG CNS target engagement and microglia activation were measured by immunohistochemistry and flow cytometry. Microglia transcriptomics were assessed by RNAseq.

Results

Here, we report that peripheral injection of anti-Myelin oligodendrocyte glycoprotein (MOG) monoclonal antibodies (mAbs) triggers a rapid and tightly regulated microglia Ki-67⁺ proliferative burst in both brain and spinal cord. This microglia activation was FcR-dependent as only Fc effector-competent but not Fc effectorless aglycosylated antibodies triggered the proliferative response. Accordingly, anti-MOG induced microglia proliferation was fully abrogated in FcR knockout mice. The anti-MOG driven microglia proliferative response was associated with a transient and tightly-regulated gene expression signature of largely proliferation-associated genes. Moreover, we determined that anti-MOG-induced microglia activation in vivo was dependent on BTK, a signaling node downstream of FcRs. Specifically, we found that anti-MOG microglia response was amplified in BTK^e41K knock-in mice that express a constitutively active form of BTK and was blunted in mice treated with ibrutinib, a CNS penetrant small molecule BTK inhibitor.

Conclusions

Together, these results demonstrate the first report of an in vivo physiological function for FcR and BTK signaling in microglia and we propose that this model provides a novel tool to further dissect the roles of microglia-specific FcR and BTK driven responses to antibodies in CNS homeostasis and disease.

Background

Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system, leading to substantial and irreversible disability. HLA-DRB1*15 gene confers the greatest MS risk, with MS 15+ individuals displaying more severe inflammation and demyelination. Yet, the mechanisms underlying this specific genotype remain elusive. Astrocytes are likely early and active contributors of MS pathogenesis due to their integral role in blood-brain barrier maintenance, neurotrophic support, and immune regulation. Dysfunctional astrocytes can lead to cytotoxicity, engaging with activated microglia to create a toxic cycle of inflammation and neurodegeneration. However, astrocyte topography in the MS motor cortex and its relationships with genotype and pathological outcome have been overlooked and is therefore, the focus of this study.

Objectives

To characterize astrocyte pathology in the post-mortem MS motor cortex by assessing the morphological phenotypes of astrocyte populations in MS, evaluating the influence of HLA-DRB1*15 status, and relating pathological outcomes to astroglial phenotypes.

Methods

A cohort of pathological confirmed MS (n=47; HLA-DRB1*15-, n=26; HLA-DRB1*15+, n=21), and non-neurological control cases (n=7) was used. Adjacent formalin-fixed, paraffin-embedded motor cortical sections were immunolabelled for astrocytes (ALDH1L1, GFAP). Pixel density (pixel/mm²) was used to asses astrocyte expression in pre-defined trajectories spaced at systematic intervals of the motor cortex and correlated to genotype status, neuronal (NeuN), and microglia/macrophage densities (IBA1; CD68).

Results

ALDH1L1 expression was greatest in the grey matter (p<0.0001), whereas GFAP expression was greatest in the white matter (p<0.0001). GFAP was influenced by HLA-DRB1*15, especially in cases equal to or younger than the median age of 62-years old, with 15+ individuals expressing greater GFAP expression than their 15- counterparts (p=0.014). Although CD68 correlation with GFAP was lost in MS (r=-0.107, p=0.473), ALDH1L1 positively correlated with CD68 in HLA-DRB1*15-cases (r=-.549, p=0.004), especially in cases older than 62-years old (r=0.936, p=0.006).

Conclusions

The striking differences between ALDH1L1 and GFAP, suggest that there are distinct astrocyte populations present in the MS motor cortex, which may play a crucial role in understanding MS heterogeneity. HLA-DRB1*15 genotype appears to influences astrocyte reactivity and likely mitigates components of the astrocyte-microglia/macrophage relationship. These findings suggest a significant impact of genetic background on MS astrocyte populations, which when disrupted from appropriate expression, may contribute to cytotoxic inflammation and subsequent disability.

Background

Microglia are a unique type of brain-resident immune cell that secretes essential neurotrophic factors, promotes myelinogenesis, provides immune defense, clears debris and phagocytoses apoptotic cells. While this wide array of functional properties is suggestive of microglia heterogeneity, few microglia subsets have been described in the healthy brain thus far.

Objectives

To identify novel microglia subsets present in the steady-state brain and to characterize their unique functional roles.

Methods

Microglia isolated from mice and non-human primates were characterized by flow cytometry, electron microscopy and proteomics.

Results

In microglia isolated from mice and non-human primates and then analyzed by flow cytometry, we serendipitously observed that cellular autofluorescence (AF) presented as a bimodally-distributed signal which identified two subsets of microglia: AF-positive (AF⁺) and AF-negative (AF^–). While these subsets were present across the brain and maintained at a roughly 2:1 ratio (AF⁺:AF^–) throughout most of adulthood, microglia AF increased linearly and exclusively within the AF⁺ subset, while the AF^– subset continued to remain free of AF. Electron microscopy of FACS-isolated AF⁺ microglia revealed large and frequent lysosomal storage bodies, which contained lipids and electron dense material that increased in size and complexity withaging. Proteomic analysis of AF subsets revealed an overrepresentation of endolysosomal, autophagic, catabolic, and mTOR-related proteins in AF⁺ microglia, pointing to a unique dependence of the AF⁺ subset on lysosomal function. Accordingly, genetic disruption of lysosomal or autophagic pathways increased and decreased, respectively, the accumulation of AF in the AF⁺ subset while the AF^– subset remained unaffected. Lastly, both aging and lysosomal disruption differentially impacted AF subsets, as demonstrated by the increased cellular ROS content and apoptotic rates in AF⁺ microglia, which also correlated with diminished cell numbers of AF⁺ microglia at advanced ages.

Conclusions

AF⁺ and AF^– subsets represent discrete populations of microglia, present in healthy brain and marked by distinct subcellular content likely reflective of unique functional roles, and in particular distinct CNS clearance functions in steady-state and aging. The increased accumulation of AF material, restricted to AF⁺ microglia, uniquely impacts their physiology as indicated by elevated cellular ROS and their decreased survival in aging, factors possibly contributing to age-related cognitive decline.

Background

Studies from our lab have reported extensive presence of myelin particles in the leptomeninges of multiple sclerosis (MS) cases, hinting at a potential role of this debris in instigating MS-related immunological responses.

Objectives

Here, to gain further insight into this possibility we closely looked at meningeal myelin fragments for the presence of posttranslational modifications (citrullination) which render myelin debris more immunogenic. We also tested whether citrullinated myelin is associated with antigen presenting cells relevant to induction of autoimmunity in MS, i.e B cells.

Methods

We performed immunohistochemistry experiments on post-mortem meningeal material coming from 8 SPMS patients (age: 61.29±4.66, disease duration: 30±4.40 years) and 7 non-neurological controls (age: 55.88±5.32 years). In addition, using confocal colocalization analysis tools, we investigated the presence of citrullinated myelin basic protein (MBP) in CD19⁺ B lymphocytes in MS meninges.

Results

Compared with tissue from non-neurological controls, meninges of MS patients presented with a larger surface proportion of citrullinated proteins (p=0.03). In MS material, this effect was accompanied by the presence of meningeal CD19⁺ B-cells. Almost all the analyzed CD19⁺ B-cells showed high citrulline content (n=144, 99% citrulline positive cells; mean % citrulline inside B-cells= 50.81±3.86 %) and 95.13% of these cells were also positive for myelin basic protein (MBP; median percent MBP which colocalizes with CD19= 42.05%). Interestingly, Mander´s coefficient analysis to colocalize MBP and citrulline inside B-cells underlined that almost half of the lymphocytic cellular surface was occupied by citrullinated MBP (40.06±3.23 %).

Conclusions

Our results are indicative of a B cell-mediated uptake mechanism that operates in MS meninges to clear up highly immunogenic myelin fragments. Although the question remains on whether myelin citrullination happens in the absence of a primary immunological response, studies in cuprizone mouse models of MS have highlighted that MBP citrullination already occurs before demyelination via intramyelinic Ca²⁺-dependent activation of protein arginine deiminases. This evidence combined with previous studies showing abundant citrulline content in both MS normal appearing white matter and white matter lesion support the concept that a primary cytodegenerative process instigates demyelination, which elicits secondary immune reactions in MS.

Background

Neuromyelitis optica spectrum disease (NMOSD) and multiple sclerosis (MS) have a different pathophysiology. Accumulating evidence suggests that the choroid plexus plays a pivotal role in the pathogenesis of MS. However, MRI data comparing the choroid plexus volume between MS and NMOSD are scarce.

Objectives

To compare the choroid plexus volume in MS vs. NMOSD in vivo using high-resolution 3D MRI data. Migraine patients and healthy individuals served as control groups.

Methods

We included 95 MS patients [45% secondary progressive (SP); mean age 51.0±11.5 years; disease duration 20.8±10.4 years, 62% female; median Expanded Disability Status Scale (EDSS) 4.0], 43 NMOSD patients [28/43 anti-aquaporin 4 antibody positive; 11/43 anti-myelin oligodendrocyte glycoprotein antibody positive; 87% female; mean age 50.0±13.8 years; disease duration 6.8±7.3 years, median EDSS 3.0], 38 migraine patients [mean age 39±13 years, 79% female; 15/38 migraine with aura] and 65 healthy individuals [HCs, mean age 41±17 years, 48% female]. The choroid plexus of the lateral ventricles and T2-weighted (T2w) white matter lesions (WMLs) were segmented fully automated on T1-weighted (T1w) magnetization-prepared rapid gradient echo (MPRAGE) images and fluid attenuated inversion recovery sequences (FLAIR, voxel size of both sequences 1x1x1 mm³), respectively, using a supervised deep learning algorithm (multi-dimensional gated recurrent units). Total intracranial volume (TIV) and lateral ventricle volumes were assessed fully automated using Freesurfer. All outputs were reviewed and manually corrected (if necessary) using 3D-Slicer by trained raters who were blinded to the clinical information. Group differences were analyzed using multivariable generalized linear models (GLMs) adjusted for age, gender, TIV and lateral ventricle volume. Cohens’ d was used to calculate the standardized difference between the respective groups. Given p-values are adjusted for multiple comparisons (Bonferroni).

Results

Mean choroid plexus was larger in MS compared to NMOSD (1907±455 vs. 1467±408 µl; p<0.001, d=0.86), HCs (1663±424 µl; p=0.007, d=1.17) and migraine (1527±366 µl; p=0.02, d=0.72). There was no statistical difference in the choroid plexus volume between NMOSD, migraine and HCs. The choroid plexus was marginally larger in RRMS than SPMS (1959±482 vs. 1875±476 µl; p=0.28; d=0.17) and in untreated MS patients compared to MS patients on disease modifying therapy (2111±382 vs. 1876±459 µl; p=0.36). However, these differences did not reach statistical significance after correction for multiple comparisons. There was no association between the choroid plexus volume and total T2w WML volume in MS.

Conclusions

Patients with MS have larger choroid plexus than HCs, migraine and NMOSD patients. Further studies are warranted to investigate the respective roles of the choroid plexus in the pathogenesis of MS and NMOSD.

Background

Multiple sclerosis (MS) is a demyelinating condition of the central nervous system (CNS) mediated by a complex interplay of adaptive and innate immune cells. In MS and its model, experimental autoimmune encephalomyelitis (EAE), the receptor for CCL2 chemokine, CCR2, is critical for monocyte/macrophage migration into the CNS to exert their effector pathological functions. Recently, we showed that extracellular matrix metalloproteinase inducer (EMMPRIN), a glycoprotein present on monocyte/macrophage membrane, aids aerobic glycolysis (a pro-inflammatory metabolic program) within inflammatory macrophages by regulating the surface levels of monocarboxylate transporter (MCT-4), a lactate transporter.

Objectives

Our earlier studies found that neutralization of EMMPRIN activity by function blocking antibodies ameliorated EAE severity. Here, to understand specific functions and mechanisms of EMMPRIN on CCR2+ monocyte/macrophages, we investigated genetic deletion of EMMPRIN in CCR2+ monocytes.

Methods

Full length EMMPRIN was floxed using CRISPR/Cas9 (inserted 5’ flox in 1^st exon and 3’ flox in 8^th exon of EMMPRIN gene, Bsg2). These EMMPRIN ‘floxed’ mice were then crossed with CCR2CreERT2+mKate2 mice to yield CCR2CreERT2:EMMPRIN^fl/fl (EMMPRIN^-/- CCR2+) tamoxifen inducible mice. EMMPRIN deletion was induced by injection of 2 mg tamoxifen/mouse every 48h starting at day 2 post EAE induction. The last injection was given on day 14. Some groups had resumption of tamoxifen regimen at day 36 until harvest. In vitro, bone marrow derived macrophages (BMDMs) were exposed to 5μM 4-hydroxytamoxifen for 24h before stimulating with LPS for another 24h for quantitative proteomics and qRT-PCR analysis.

Results

EMMPRIN^-/- CCR2+ mice exhibited significantly delayed onset of EAE signs; disease severity was significantly reduced after clinical signs set in. EMMRIN^-/- CCR2+ mice had significantly reduced number of perivascular cuffs during peak EAE (day 18), during which the spinal cord had significantly reduced CCR2+EMMPRIN+ monocyte/macrophages. These mice harbored elevated numbers of CCR2+ monocytes in lymph nodes suggesting an impairment of trafficking of EMMPRIN^-/- CCR2+ monocytes into the CNS. In vitro, we observed alteration of proteome in EMMPRIN^-/- macrophages, which was skewed towards gluconeogenesis metabolic program.

Conclusions

Selective EMMPRIN deletion in CCR2+ monocyte/macrophages alters metabolic program and interferes with their migration into EAE CNS. EMMPRIN on myeloid cells may constitute a therapeutic target in MS.

Background

Natalizumab, a humanized monoclonal antibody (mAb) against α4-integrin, reduces the number of dendritic cells (DC) in cerebral perivascular spaces in multiple sclerosis (MS). Selective deletion of α4-integrin in CD11c⁺ cells should curtail their migration to the CNS and ameliorate experimental autoimmune encephalomyelitis (EAE).

Objectives

We intended to invesigate the effects of α4-integrin antagonism among CD11c⁺ cells on the clinical outcomes in a mouse model of EAE.

Methods

We generated CD11c.Cre^+/-ITGA4^fl/fl C57BL/6 mice to selectively delete α4-integrin in CD11c⁺ cells. Active immunization and adoptive transfer EAE models were employed and compared with wild type controls. Multi-parameter flow cytometry was utilized to immunophenotype leukocyte subsets. Results from murine model analyses were reconfirmed via single-cell RNA sequencing (scRNA-seq) of human blood and cerebrospinal fluid (CSF) samples to profile individual cells

Results

In our mouse model α4-integrin expression by CD11c⁺ cells was significantly reduced in primary and secondary lymphoid organs in CD11c.Cre^+/-ITGA4^fl/fl mice. In active EAE, a delayed disease onset was observed in CD11c.Cre^+/-ITGA4^fl/fl mice, during which CD11c⁺CD88⁺ cells were sequestered in the blood. Upon clinical EAE onset, CD11c⁺CD88⁺ cells appeared in the CNS and expressed CD317⁺. In adoptive transfer experiments, CD11c.Cre^+/-ITGA4^fl/fl mice had ameliorated clinical disease phenotype associated with significantly diminished numbers of CNS CD11c⁺CD88⁺CD317⁺ cells. In human CSF from subjects with neuroinflammation, microglia-like cells display coincident expression of ITGAX (CD11c), C5AR1 (CD88), and BST2 (CD317). In mice, we show that only activated, but not naïve microglia expressed CD11c, CD88, and CD317. Finally, anti-CD317 treatment prior to clinical EAE substantially enhanced recovery in mice.

Conclusions

CD11c⁺CD88⁺CD317⁺ myeloid cells in the CNS promote inflammatory damage with direct temporal correlation with the clinical phase of the disease in EAE model in mice. Transcriptional analysis identifies ITGAX (CD11c) C5AR1 (CD88) BST2 (CD317) expressing cells as a distinct myeloid subset in human CSF collected from patients with neuroinflammation. The disease-propagating effects of these cells in EAE can be effectively antagonized using anti-CD317 mAb therapy.

Background

B cell depleting anti-CD20 antibodies (ab) are highly effective in multiple sclerosis (MS). Besides B cells, a population of proinflammatory T cells express CD20. The origin of these CD20 positive T cells and whether their depletion contributes to the clinical effect of anti-CD20 is unclear.

Objectives

This study is focused on characterizing CD20+ T cells both in naive and experimental autoimmune encepahalomyelitis (EAE) mice and in humans.

Methods

CD20+ T cells were analyzed for their phenotype, cytokine expression and developmental state using flow cytometry, FACS, ELISA, RT pcr and microscopy. Spleens, inguinal lymph nodes, blood and spinal cord from wild type, 2D2, µMT and CD20KO mice as well as PBMCs from MS patients were examined. Splenoculture and B cell-T cell coculture with 2D2 T cells and various B cells (wt, CD20KO, membrane stained) were used to analyze CD20 content and transfer. EAE was induced by immunization of the mice with CFA and MOG peptide.

Results

When compared to CD20- T cells, CD20+ T cells show enhanced features of pathogenicity both in mice as well as in patients with MS. In wild-type mice, CD20+ T cells expand during EAE, while B cell-deficient mice do not exhibit CD20+ T cells. T cells themselves are not able to generate CD20 and in splenocyte cultures, de novo development of CD20+ T cells is strictly dependent on the presence of B cells expressing CD20. In direct B cell-T cell cocultures, CD20 is transferred from B cells to T cells via trogocytosis. Along the same lines, transfer of CD20 expressing B cells into B cell-deficient mice results in the development of CD20+ T cells.

Conclusions

CD20 on T cells relies on its transfer from B cells via trogocytosis. Thus, T cell CD20 is a marker for their recent activating interaction with a B cell, explaining the pronounced pro-inflammatory phenotype of these T cells. These data suggest that depletion of CD20+ T cells may substantially support the effectiveness of anti-CD20 ab therapy in MS, and their reappearance in the blood may serve as a marker for reemerging pathogenic B cell – T cell interaction.

Background

Multiple sclerosis (MS) is an auto-immune disease characterized by inflammation, demyelination and neural degeneration. While MS etiology is still uncertain, recent studies propose an interplay between genetic and environmental factors but MS genetic determinants are still poorly understood. Recent advances in 3D cerebral organoid cultures, derived from induced pluripotent stem cells (iPSCs), provide new avenues to investigate human disorders. Cerebral organoids contain ventricular structures aligned by neural stem cells, progenitor cells in various stages of differentiation, and neurons in a typical inside-out stratified layout. Furthermore, it has been shown that myelination can be induced in those neurons.

Objectives

We propose here to use human iPSC derived cerebral organoids to study the genetic components of multiple sclerosis. The lack of blood vessels and immune cells in cerebral organoids allows the study of the effect of MS genetic component on neural cells.

Methods

Cerebral organoids were derived from iPS cells of patients with MS. We analyzed stem cell proliferation, migration and differentiation in neuronal and glial lineages in MS organoids compared to healthy control organoids at 42 days in vitro.

Results

MS cerebral organoids seemed to grow faster compared to healthy control organoids, suggesting a higher stem cell proliferation rate. Immunostainings for stem cell marker SOX2 and neuroblast marker DCX revealed that the stem cell pool localized in the Ventricular/Subventricular Zone was larger in MS cerebral organoids compared to control. A lower DCX intensity was detected in MS cerebral organoids, suggesting that MS cerebral organoids might have developed an enlarged stem cell pool at the expense of the neuroblast population. A preliminary quantification of cortical neuron marker CTIP2 did not show a statistically significant difference between MS organoids and healthy controls, suggesting that neuronal maturation might not be affected. An analysis of apoptosis marker CC3 displayed an increase of CC3+ cell numbers in MS organoids, particularly in cortical plate, with little to no cell death in the stem cell pools in both organoid populations. A further analysis of DNA damage and senescence in stem cells as well as oligodendrocyte maturation will be performed.

Conclusions

This study will give new insight on the origin and evolution of the disease and will help to identify potential target for therapeutic strategies designed to promote myelin repair in MS.

Background

Patients with multiple sclerosis (MS) displayed high levels of IgM, IgA and IgG in the cerebrospinal fluid (CSF). In particular, intrathecal immunoglobulin M (IgM) synthesis has been suggested as a prognostic marker of a more rapid and severe disease progression in MS.

Objectives

Investigate whether IgM production is associated with a specific CSF inflammatory profile in naïve MS patients at the time of diagnosis.

Methods

CSF protein levels of IgM, IgA, IgG and of 34 inflammatory mediators were analysed using Bio-Plex Multiplex immunoassay in 103 naïve relapsing-remitting MS patients (RRMS) and 36 patients with other neurological disorders.CSF IgM levels were also correlated with clinical and neuroradiological measures (advanced 3T-MRI parameters) at diagnosis and after 2 years of follow-up.

Results

A 45.6% increase in CSF IgM levels was found in MS patients compared to controls (p=0.013), while no significant differences in IgG (p=0.360) and IgA (p=0.700) levels between the two groups have been detected. CSF IgM levels correlated with higher paired CSF levels of CXCL13 (p=0.039), CCL21 (p=0.023), IL-10 (p=0.025), IL-12p70 (p=0.020), CX3CL1 (p=0.036) and CHI3L1 (p=0.048) and were associated with earlier age of patients at diagnosis (p=0.008), white matter lesions (WMLs) number (p=0.039) and disease activity (p=0.033) after 2 years of follow-up.

Conclusions

IgM are the most abundant immunoglobulins present at diagnosis in naïve RRMS patients compared to other neurological conditions at the time of diagnosis and their association with further molecules related to both B-cell immunity (IL-10) and recruitment (CXCL13 and CCL21) and to macrophage/microglia activity (IL-12_p70, CX3CL1 and CHI3L1) suggestsa link between humoral and innate intrathecal immunity.

Background

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory demyelinating disease of the central nervous system mainly associated with autoantibodies against the glial water channel protein aquaporin-4 (AQP4). A number of NMOSD related animal models have recently been reported. For example, general NMOSD models are produced by peripheral injection of immunoglobulin from NMOSD patients (NMO-IgG) in experimental autoimmune encephalomyelitis mice or intra-cerebral administration of NMO-IgG with human complement in naïve mice. In addition, AQP4-specific adoptive transfer model was also reported. But AQP4 immune process is not involved in these NMOSD models. On the other hand, creation of an AQP4-immunized mice model with clinical and histologic manifestations of CNS autoimmunity has proven challenging.

Objectives

In the present study, we tried to create AQP4 peptide-induced experimental autoimmune encephalomyelitice mice as NMOSD model.

Methods

Female C57BL/6J mice were used. Mice were subcutaneously immunized with 200 μg of AQP4 p201-220 peptide emulsified in complete Freund’s adjuvant supplemented with Mycobacterium tuberculosis extract H37Ra (Day 0). Pertussis toxin (400 ng) was administered at Days 0 and 2. Mice were sequentially scored for clinical symptoms according to the following scale: 0, no disease; 1, limp tail; 2, hind limb weakness; 3, hind limb paresis; 4, hind limb paralysis; 5, hind limb and fore limb paralysis; 6, moribundity and death.

Results

Total ten mice were immunized, four of which showed clinical symptoms within Day 34; two mice were clinical score 2, the other mice were clinical score 3.

Conclusions

NMOSD like model can be created by AQP4-immunization. Now, we are conducting additional experiments to examine the detailed characterization of this model, for example histopathological profiling such as AQP4 and astrocyte pathology in the spinal cord.