Background

Plasma neurofilament light(pNFL) levels account for 30-60% of the variance in CSF neurofilament light(cNFL) levels depending on the study. Age, disability, relapses, and the presence of contrast enhancing MRI lesions can increase both pNFL and cNFL. Additional nervous system biomarkers can now be studied in plasma. Understanding the factors that increase their variability in blood may be helpful in normalizing levels to better understand what levels are concerning for ongoing disease activity.

Objectives

To evaluate factors contributing to blood and cerebrospinal fluid(CSF) discordance and determine if a correction of blood levels can better estimate what is happening in the CSF compartment.

Methods

Matched plasma and CSF samples were identified in the Rocky Mountain Multiple Sclerosis Center Biorepository at the University of Colorado. Neurofilament Light(NFL), Glial Fibrillary Acidic Protein(GFAP), tau, and Ubiquitin carboxy-terminal hydrolase L1(UCHL1) levels were assessed using Single Molecule Array(SIMOA) in a Quanterix SR-X machine. Analyses were done on log transformed NFL concentrations.

Results

Fifty-seven patients had matched plasma and cerebrospinal fluid samples evaluated for neurofilament light which included 24 patients with multiple sclerosis(MS), 7 with neuromyelitis optica spectrum disorder(NMOSD), and 18 patients with headache whose opening pressures were <20cmH₂O. These patients had a mean age of 46.5(+/-11.2) years, 75% female, mean albumin index of 6.3(+/-5.5), and BMI of 27.4(+/-5.8). The CSF and plasma concentrations in pg/ml were for NFL 1059.3(+/-3052.4) and 12.2(+/-32.4), GFAP 7621.5(+/-9713.4) and 52.9(+/-39.7), tau 41.5(+/-41.3) and 1.3(+/-0.8), UCHL1 1356.0(+/-1677.1) and 23.6(+/-32.8). Respectively the CSF vs plasma Spearman correlations (95% confidence intervals, p values) were: 0.79(0.67-0.87,<0.0001), 0.67(0.50-0.79,<0.0001), 0.75(0.61-0.85,<0.0001), and 0.70(0.54-0.81,<0.0001). Adjusting individually for age, BMI, or albumin index did not affect the correlation for NFL.

Conclusions

Blood and CSF levels of NFL, GFAP, tau, and UCHL1 correlated well. Models will be created that explore the relationship between Blood and CSF levels of these biomarkers.

Background

In the development of the sensitive single molecule array (SIMOA) technology, serum and blood plasma from EDTA collection tubes were used to verify and validate blood levels of NFL, GFAP, Tau and UCHL1 across healthy controls^[1]. As the need arises to establish extensive baseline levels of these neurobiomarkers in order to better evaluate neurodegeneration in a wide variety of patients including multiple sclerosis (MS) patients, a validation study across a variety of blood collection anticoagulants is necessary to ensure there are no significant differences in blood levels due to the additives themselves.

Objectives

To determine whether SIMOA results are reliable and comparable within patients and between cohorts, we measured blood levels of the neurobiomarkers neurofilament (NFL), glial fibrillary acidic protein (GFAP), tau and ubiquitin C-terminal hydrolase L1 (UCHL1) in samples collected with different blood collection additives.

Methods

Serum and blood plasma were collected voluntarily from either headache or healthy control patients in one of four different blood collection tubes representing the 4 most common types of anticoagulant: none (serum), EDTA, sodium heparin (hep) and sodium citrate (NaC). Plasma and serum were isolated from whole blood by centrifugation at 1500 x g for 20 minutes. Plasma was centrifuged at 400 x g for 10 minutes to further deplete cells. Biomarker levels of NFL, GFAP, Tau and UCHL1 were measured via SIMOA with the Neuro4Plex A Advantage kit in the Quanterix SR-X machine according to manufacturer instructions. Statistical comparisons were made using GraphPad Prism analysis software.

Results

No statistically significant differences in blood concentrations were found between the anticoagulants for the NFL, GFAP or UCHL1 biomarkers in either the headache patients or the healthy control patients. However, Tau levels were significantly lower in all serum samples (p value <0.0001) from both patient cohorts with average levels 65-80% lower than plasma.

Conclusions

Use of serum should be avoided when establishing baseline blood levels of the neurobiomarker Tau on the SIMOA platform.

Background

Blood neurofilament light (NfL) levels have been linked to multiple sclerosis (MS) activity and progression but are affected by factors such as age and body mass index (BMI). Less is known about what factors affect blood levels of Glial Fibrillary Acid Protein (GFAP), Ubiquitin Carboxy-Terminal Hydrolase L1 (UCH-L1), and Tau. Single Molecule Array (SIMOA) platforms allow multiplex measurement of these biomarkers with high sensitivity.

Objectives

To evaluate factors associated with higher levels of four plasma biomarkers—NfL, GFAP, UCH-L1, and Tau—in individuals with MS on immunotherapy.

Methods

Subjects with MS between 18-65 years taking dimethyl fumarate (n=40), fingolimod (n=37), natalizumab (n=47), or rituximab (n=90) for at least 1 year were identified from Rocky Mountain MS Center Biorepository. Neuro 4-plex A plasma assays were conducted on the Quanterix SR-X SIMOA platform. Biomarker concentrations were log transformed. For each biomarker, summary statistics were generated, and logistic regressions on the probability of having a level in the top quartile, adjusting for age, were performed with different explanatory variables including gender, BMI, disease duration, length on disease modifying therapy (DMT), DMT type, and MS subtype (relapsing MS [RMS] or progressive MS [PMS]). All statistics were generated in SAS.

Results

Included were 214 subjects (194 RMS, 20 PMS; 70.3% female; 86.9% Caucasian) with mean age of 44.1(SD 9.8). Mean disease and treatment durations were 150.7(SD 95.7) and 49.7(SD 33.5) months, respectively. Means (IQR) for NfL, GFAP, UCH-L1 and Tau were 6.6(3.9-7.1), 66.9(45.5-81.4), 11.5(7.1-13.8), and 1.2(0.8-1.5) pg/ml, respectively. NfL, GFAP, and UCH-L1 increased with age. (Remainder of results are given age-adjusted.) PMS was more likely than RMS to be in the top quartile for NfL (OR 3.5,p=0.01), GFAP (OR 2.6,p=0.06), and UCH-L1 (OR 2.8,p=0.04). Longer disease duration (5 years) increased the likelihood of elevated NfL (OR 1.3,p=0.02) and elevated GFAP (OR 1.3,p=0.03). Higher BMI (5 units) decreased the likelihood of elevated NfL (OR 0.6,p=0.0007) and GFAP (OR 0.8,p=0.03) but increased the likelihood of having an elevated Tau (OR 1.4,p=0.002). Ethnicity and treatment duration had no effect, but men were more likely to have elevated UCH-L1 (OR 2.1,p=0.03) and lower Tau (OR 0.2,p=0.0004). Comparing DMTs, no biomarker differences were observed except subjects on rituximab and dimethyl fumarate were less likely to have elevated Tau.

Conclusions

Plasma NfL, GFAP, and UCH-L1 are promising biomarkers to differentiate relapsing from progressive MS. Age and BMI should be incorporated into biomarker models to determine normal thresholds. No differences were observed between treatments for NFL, GFAP, or UCH-L1, but subjects on dimethyl fumarate and rituximab were less likely to have elevated Tau. Lack of randomization or repeated measures limited comparative effectiveness analyses.

Background

Depletion of B cells in patients with relapsing multiple sclerosis (RMS) using anti-CD20 monoclonal antibodies (mAbs) reduces annualized relapse rates and inflammatory lesion activity on magnetic resonance imaging, and delays time to confirmed disability worsening. Anti-CD20 mAbs ocrelizumab and rituximab are administered by intravenous infusion in clinic; ofatumumab is administered subcutaneously with a pre-filled syringe or autoinjector (AI) pen, facilitating self-administration. No outcome data exist relating to transition of patients treated with ocrelizumab or rituximab to ofatumumab.

Objectives

OLIKOS is a 12 month, prospective, single-arm, multicenter phase 3b study that will explore maintained efficacy of ofatumumab in patients with RMS who transition from intravenous anti-CD20 mAb therapy.

Methods

About 100 adults with RMS will be enrolled at 10-20 centers in the USA. Eligible patients will have been previously treated with 2-5 consecutive courses of intravenous ocrelizumab or rituximab (other anti-CD20 mAbs are excluded), with last dose 4-9 months before OLIKOS baseline. Other inclusion criteria are Expanded Disability Status Scale score 5.5 or lower at screening and CD19 B cells depleted to below 1% at baseline. Patients with suboptimal response to anti-CD20 therapy in the previous 6 months (relapse, ≥2 active gadolinium-enhancing [Gd+] lesions, any new/enlarging T2 lesions, clinical worsening), or who discontinued anti-CD20 therapy because of severe infusion-related reactions or recurrent infections, or with progressive disease, will be excluded. All participants will receive subcutaneous ofatumumab 20 mg administered by AI pen on Days 1, 7 and 14, then monthly in Months 1-12. The primary endpoint will be no change or a reduction in Gd+ lesion count at Month 12. Secondary endpoints will be participant retention and changes in immune biomarkers, treatment satisfaction, safety and tolerability at Months 6 and 12. There will be a 6 month interim analysis.

Results

The detailed study design will be presented. OLIKOS will complement the ofatumumab phase 3 program in RMS by generating maintained efficacy, retention and satisfaction data based on monthly subcutaneous drug delivery with the AI pen in patients previously treated with ocrelizumab or rituximab.

Conclusions

OLIKOS will provide important data on the maintained efficacy of ofatumumab in patients with RMS transitioning from intravenous anti-CD20 therapies.

Background

Ocrelizumab (OCR), used in the treatment of multiple sclerosis (MS), is a monoclonal antibody targeting CD20, resulting in B-cell depletion.

Objectives

To describe the patient two-year experience of MS patients treated with OCR at the Rocky Mountain MS Center at the University of Colorado.

Methods

94 randomly selected MS patients prescribed OCR prior to May 2018 at the Rocky Mountain MS Center at the University of Colorado were retrospectively followed for up to two years from OCR start date. Lab data, relapse history, adverse events, MRI outcomes, disease history and patient characteristics were collected. Descriptive statistics were used to describe the sample group.

Results

Patients had a mean age of 44.2 years at date of first infusion; were predominantly female (75.5%); and had a mean MS disease duration of 10.4 years. Of the sample group, 76 (80.9%), 16 (17.0%), and 2 (2.1%) were relapsing-remitting, secondary progressive, and primary progressive MS, respectively. Two (2.1%), 1 (1.2%), and 6 (7.4%) patients experienced a clinical relapse, enhancing lesion and new T2 lesion, respectively. Of 48 patients with available MRI data for re-baselining after initiation of OCR, 1 (2.1%) patient had a new T2 lesion. Twenty (21.3%) patients discontinued OCR at our center at <24 months. Nine patients were lost to follow-up or relocated care, 7 patients discontinued due to issues with insurance, 1 patient discontinued due to adverse events, specifically hypogammaglobulinemia, and 3 patients discontinued due to other reasons, such as family planning and concern for cancer. During the first and second infusion course, 19 (20.2%) and 7 (7.4%) experienced an infusion reaction that interrupted the OCR infusion, respectively, and none experienced a life-threatening reaction or were hospitalized. After initiating OCR, 3 patients were diagnosed with basal cell carcinoma. Infections resulting in an emergency department visit or hospitalization occurred in 11 (11.7%) and 1 (1.1%) patients, respectively. Eleven (11.7%) patients experienced lymphopenia ≤500/mm3, and 2 (2.1%) experienced neutropenia ≤1000/mm3. Seven (7.4%) patients experienced IgG levels ≤500, 25 (26.6%) experienced IgM levels ≤40.

Conclusions

Our data suggests OCR is safe and effective in the treatment of MS. Additional data on an increased sample size will be presented.

Background

Anti-CD20 treatment has been associated with both lymphopenia and hypogammaglobulinemia, which can increase the risk of infection. Who develops lymphopenia and hypogammaglobulinemia and the time course is not well understood.

Objectives

To evaluate risk factors in developing lymphopenia and hypogammaglobulinemia in anti-CD20 treated patients with multiple sclerosis (MS).

Methods

A random sample of patients with neuroimmune conditions treated with rituximab at the Rocky Mountain MS Center at the University of Colorado were identified and followed retrospectively. Patients who switched to ocrelizumab remained in the study. Patient characteristics, IgG, IgM, and absolute lymphocyte counts on rituximab/ocrelizumab were analyzed.

Results

Laboratory data on 546 patients were studied including 527 MS and 17 neuromyelitis optica spectrum disorder patients with mean disease duration of 9.2 years, mean age of 44.1, 68.7% women and 76.5% Caucasians. Patients were followed for a mean of 30.2 months with a mean cumulative rituximab dose of 3,312mg. Of the 527 MS patients, 96 (17.6%) switched to ocrelizumab (mean cumulative ocrelizumab dose of 1,175mg). Fifty-seven (10.4%) patients had lymphopenia (≤500cells/mm³), 38 (7.4%) low IgG (≤500 mg/dL), and 143 (37.9%) low IgM (≤40 mg/dL). A decrease of 31.5mg/dl per year in IgG from 920mg/dL in year 1 to 857mg/dL in year 3 was observed. Respectively, median time to lymphopenia, low IgG, and low IgM were 11.3, 36.2 and 23.6 months. Of patients who developed low IgG (≤500 mg/dL), 73.9% had a preceding (34.8%) or concurrent initial low IgM (39.1%). Higher doses (per gram) of anti-CD20 increased the odds of low IgG (OR: 1.28, 95% CI: 1.12-1.47; p<0.001) and low IgM (OR: 1.31, 95% CI: 1.18-1.45; p<0.001), but not of lymphopenia (p=0.246). Similarly, follow-up time (months) on anti-CD20 therapy increased the odds of low IgG (OR: 1.49, 95% CI: 1.23-1.80; p<0.001) and low IgM (OR: 1.45, 95% CI: 1.28-1.65; p<0.001), but not of lymphopenia (p=0.237). Increasing age was associated with an increased odds of lymphopenia (OR: 1.03, 95% CI: 1.00-1.05; p=0.030), but not low IgG (p=0.27) or IgM (p=0.18). Males had greater odds of low IgM values compared to females (OR: 2.87, 95% CI: 1.84-4.48; p<0.001).

Conclusions

MS patients treated with anti-CD20 therapies frequently develop low IgM. Lymphopenia and low IgG are less common but should be monitored given their association with an increased risk of infections.

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 management of GI symptoms associated with the initiation of DMF has evolved over time with real world experience. The combined effect of GI management strategies has not been assessed in randomized studies and their overall impact on the incidence of GI symptoms and therapy discontinuation due to GI events is currently unclear.

Objectives

To compare discontinuation rate due to gastrointestinal (GI) symptoms in the first year after initiating dimethyl fumarate (DMF) between an early (post launch) and recent DMF cohort of multiple sclerosis (MS) patients at two MS centers.

Methods

Data were collected through chart reviews at Rocky Mountain MS Center and Providence MS Center. The cutoff for Early versus Recent cohort was April 1, 2014. Chi-square, non-parametric, and t-tests were used to determine differences between the two cohorts. Differences in discontinuation due to a GI event for the two cohorts were compared with a Cox proportional hazards model adjusted for baseline characteristics.

Results

Medical records of 700 patients who initiated DMF between March 2013 and December 2017 were reviewed- 302 were Early and 398 Recent. At baseline, Early patients were older (50.30 vs 48.50, p=0.049), had longer disease duration [11.09 (IQR: 7.88, 16.77) vs 6.72 (4.35, 13.72), p<0.001], more history of GI disease (27.8% vs. 22.1%, p=0.099) but lower percent of seasonal allergy (17.9 vs. 24.4, p=0.048). Discontinuation for any reason was higher in Recent patients (37.4% vs. 22.2%, p<0.001). Discontinuation due to GI symptom were 8.6% in the Early patients and 12.1% in the Recent patients (p=0.178). Females [HR: 2.27 (1.12-4.60)] and patients with a history of GI condition [HR: 2.14, (1.32-3.47)] were more likely to discontinue. No significant associations were found between discontinuation and any GI events or previous exposure to natalizumab or other medications. None of the baseline or patient characteristics were found to be risk factor of GI events except study site.

Conclusions

Overall, the discontinuation rate due to GI symptoms was no different between the Early and Recent patient cohorts. However, the odds of having a GI symptom at the Rocky Mountain site were higher although discontinuation for this site was lower suggesting there may be differences in symptom reporting, data abstraction, and GI mitigation strategies between the two centers. Further research with prospective study design and standard documentation and data abstraction tool are needed.

Support: Biogen

Background

Plasma neurofilament light(pNFL) levels account for 30-60% of the variance in CSF neurofilament light(cNFL) levels depending on the study. Age, disability, relapses, and the presence of contrast enhancing MRI lesions can increase both pNFL and cNFL. Additional nervous system biomarkers can now be studied in plasma. Understanding the factors that increase their variability in blood may be helpful in normalizing levels to better understand what levels are concerning for ongoing disease activity.

Objectives

To evaluate factors contributing to blood and cerebrospinal fluid(CSF) discordance and determine if a correction of blood levels can better estimate what is happening in the CSF compartment.

Methods

Matched plasma and CSF samples were identified in the Rocky Mountain Multiple Sclerosis Center Biorepository at the University of Colorado. Neurofilament Light(NFL), Glial Fibrillary Acidic Protein(GFAP), tau, and Ubiquitin carboxy-terminal hydrolase L1(UCHL1) levels were assessed using Single Molecule Array(SIMOA) in a Quanterix SR-X machine. Analyses were done on log transformed NFL concentrations.

Results

Fifty-seven patients had matched plasma and cerebrospinal fluid samples evaluated for neurofilament light which included 24 patients with multiple sclerosis(MS), 7 with neuromyelitis optica spectrum disorder(NMOSD), and 18 patients with headache whose opening pressures were <20cmH₂O. These patients had a mean age of 46.5(+/-11.2) years, 75% female, mean albumin index of 6.3(+/-5.5), and BMI of 27.4(+/-5.8). The CSF and plasma concentrations in pg/ml were for NFL 1059.3(+/-3052.4) and 12.2(+/-32.4), GFAP 7621.5(+/-9713.4) and 52.9(+/-39.7), tau 41.5(+/-41.3) and 1.3(+/-0.8), UCHL1 1356.0(+/-1677.1) and 23.6(+/-32.8). Respectively the CSF vs plasma Spearman correlations (95% confidence intervals, p values) were: 0.79(0.67-0.87,<0.0001), 0.67(0.50-0.79,<0.0001), 0.75(0.61-0.85,<0.0001), and 0.70(0.54-0.81,<0.0001). Adjusting individually for age, BMI, or albumin index did not affect the correlation for NFL.

Conclusions

Blood and CSF levels of NFL, GFAP, tau, and UCHL1 correlated well. Models will be created that explore the relationship between Blood and CSF levels of these biomarkers.